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Full text of "The American journal of the medical sciences"



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 

(the international journal of the medical sciences.) 



EDITED BY 



I. MINIS HAYS, A.M., M.D., 



PHILADELPHIA, 



MALCOLM MORRIS, M.R.C.S., 



NEW SERIES 
VOLUME XCII. 




PHILADELPHIA: 

LEA BEOTHEES & CO. 

1886. 



Entered according to the Act of Congress, in the year 1886, by 

LEA BROTHERS & CO., 
In the Office of the Librarian of Congress. All rights reserved. 




PHILADELPHIA: 
DORNAN, PRINTER, 

634 Filbert Street. 



(Acad, 



TO READERS AND CORRESPONDENTS. 



All communications intended for insertion in the Original Department of this Journal are only 
received for consideration with the distinct understanding that they are sent for publication to this 
Journal alone, and that abstracts of them shall only appear elsewhere subsequently, and with due 
credit. Gentlemen favoring us with their communications are considered to be bound in honor to a 
strict observance of this understanding. 

Contributors who wish their articles to appear in the next number are requested to forward them 
before the 10th of July to the Editor, 

No. 1004 Walnut Street, Philadelphia, U. S. A. ; or 

No. 63 Montagu Square, Hyde Park, "W. London, England. 

Liberal compensation is made for articles used. Extra copies, in pamphlet form with cover, will 
be furnished to authors in lieu of compensation, provided the request for them be written on the manuscript. 

The following works have been received for review : 

Surgical Diseases of the Kidney. By Henry Morris, M.A., M.B., F.R.C.S., Surgeon to, and Lec- 
turer on Surgery at, Middlesex Hospital, London. Philadelphia : Lea Brothers & Co., 1886. 

The Surgical Diseases of Children. By Edmund Owen, M.B., F.R.C.S., Surgeon to the Hospital for 
Sick Children, Great Ormond Street. Philadelphia: Lea Brothers & Co., 1886. 

A Manual of Surgery. In Treatises by various Authors. In three volumes, edited by Frederick 
Treves, F.R.C.S., Surgeon to, and Lecturer on Anatomy at, the London Hospital. Philadelphia : Lea 
Brothers & Co., 1886. 

A System of Practical Medicine. By American Authors. Edited by William Pepper, M.D., LL.D. . 
Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the Univer 
sity of Pennsylvania. Assisted by Louis Starr, M.D., Clinical Professor of Diseases of Children in the 
Hospital of the University of Pennsylvania. Vol. IV. Diseases of the Genito-urinary and Cutaneous 
Systems, Medical Ophthalmology, and Otology. Philadelphia : Lea Brothers & Co., 1886. 

Diseases of the Digestive Organs in Infancy and Childhood, with Chapters on the Investigation of 
Disease, and on the General Management of Children. By Louis Starr, M.D., Clinical Professor of 
Diseases of Children in the Hospital of the University of Pennsylvania. Philadelphia : P. Blakiston, 
Son & Co., 1886. 

The Student's Manual of Venereal Diseases. By Berkeley Hill, M.D., Professor of Clinical Sur- 
gery in University College, London. Philadelphia : P. Blakiston, Son & Co., 1886. 

Dictionary of Practical Surgery. By various British Hospital Surgeons. Edited by Christopher 
Heath, F.R.C.S., Holme Professor of Clinical Surgery in University College, London. Philadelphia : 
J. B. Lippincott Co., 1886. 

Transactions of the American Gynecological Society. Vol. X. For the year 1885. New York : D. 
Appleton & Co., 1886. 

The Methods of Bacteriological Investigation. By Dr. Ferdinand Hueppe, Docent in Hygiene and 
Bacteriology in the Chemical Laboratory of R. Fresenius, at Wiesbaden. Translated by Herman M. 
Biggs, M.D., Instructor in the Carnegie Laboratory, New York. New York : D. Appleton & Co., 1886. 

Handbook of Practical Medicine. By Dr. Hermann Eichhorst, Professor of Special Pathology and 
Therapeutics and Director of the University Medical Clinic in Zurich. Vol. I. Diseases of the Circu- 
latory and Respiratory Apparatus. New York : William Wood & Co., 1886. 

Diseases of the Spinal Cord. By Byrom Bramwell, M.D., F.R.C.P. Edin., Lecturer on the Principles 
and Practice of Medicine, and on Medical Diagnosis, in the Extra-Academical School of Medicine, 
Edinburgh. New York : William Wood & Co., 1886. 

Insanity and Its Treatment. Lectures on the Treatment, Medical and Legal, of Insane Patients. By 
G. Fielding Blandford, M.D. Oxon. Together with Types of Insanity. An Illustrated Guide in 
the Physical Diagnosis of Mental Disease. By Allan McLane Hamilton, M.D., one of the Consulting- 
Physicians to the Insane Asylums of New York City, and the Hudson River State Hospital for the In- 
sane, etc. New York : William Wood & Co., 1886. 

The Genuine Works of Hippocrates. Translated from the Greek, with a Preliminary Discourse and 
Annotations. By Francis Adams, LL.D., Surgeon. In two volumes. Vol. I. New York : William 
Wood & Co., 1886. 



4 TO READERS AND CORRESPONDENTS. 

The Principles and Practice of Surgery. By Frank Hastings Hamilton, A.M., LL.D , late Profes- 
sor of the Practice of Surgery, with Operations, and of Clinical Surgery, in Bellevue Hospital Medical 
College. New York : William Wood & Co., 1886. 

The Treatment of Disease by Climate. By Herman Weber, M.D., M.R.C.P. Lond. Translated 
from the German. By Heinrich Post, M.D., M B.C. P. Lond., Physician to German Hospital, Lon- 
don, etc 

General Balneotherapeutics. By Otto Leichtenstern, M.D. Translated from the German. By 
John Macpherson, M.D., Inspector-General of Hospitals (retired). New York : William Wood & Co., 
1885. 

A Reference Handbook of the Medical Sciences, embracing the entire range of Scientific and Practi- 
cal Medicine, and Allied Sciences, by various writers. Edited by Albert H. Buck, M.D. New York : 
William Wood & Co., 1886. 

The International Encyclopaedia of Surgery. A Systematic Treatise on the Theory and Practice of 
Surgery. By Authors of various Nations. Edited by John Ashhurst, Jr., M.D., Professor of Clinical 
Surgery in the University of Pennsylvania. In Six Volumes. Vol. VI. New York : William Wood & 
Co., 1886. 

How to Care for the Insane. A Manual for Attendants in Insane Asylums. By William D. Gran- 
ger, M.D., First Assistant Physician Buffalo State Asylum for the Insane, Buffalo. New York : G. P. 
Putnam's Sons, 1886. 

The Disorders of Menstruation. A Practical Treatise. By John N. Upshur, M.D., Professor of 
Materia Medica and Therapeutics in the Medical College of Virginia, Richmond, Va. New York : G. 
P. Putnam's Sons, 1886. 

Practical Clinical Lessons on Syphilis and the Genito-urinary Diseases. By Fessenden N. Otis, 
M.D., Clinical Professor of Genito-urinary Diseases in the College of Physicians and Surgeons, New 
York. New York, 1886. Printed for the Author. 

Illustrations of Unconscious Memory in Disease, including a Theory of Alteratives. By Charles 
Cretghton, M.D. New York : J. H. Vail & Co., 1886. 

The Laws and Mechanics of Circulation, with the Principle Involved in Animal Movement. By 
Wm. H Triplett. M.D. New York : J. H. Vail & Co., 1885 

The Medical Students' Essentials of Physics. By Cordict W. Cutler, M.D., late House Surgeon 
Bellevue Hospital, etc. New York : J. H. Vail & Co., 1884. 

Monthly Nursing. By A. Worcester, A.M., M.D., Fellow of the Massachusetts Medical Society. 
Boston : D. W. Mason, 1886. 

Handbook for the Instruction of Attendants on the Insane. Boston : Cupples, Nathan & Co., 1886. 

Haschisch. A Novel. By T. Harold King. Chicago: A. C. McClurg & Co., 1886. 

On Asthma : Its Nature and Treatment. Containing an entirely new and comprehensive working 
hypothesis. By Horace Dobell, M.D., Fellow of the Royal Medical and Chirurgical Society. London : 
Smith, Elder & Co., 1886. 

On Inversion of the Uterus. With Eleven Cases Successfully Treated by the Sigmoid Repositor. A 
Post-Graduate Lecture delivered at the Chelsea Hospital for Women. By James H. Aveling, M.D., 
Senior Physician to the Hospital. London : J. & A. Churchill, 1886. 

Saint Bartholomew's Hospital Reports. Edited by W. S. Church, M.D., and John Langton, F.R.C.S. 
Vol. XXI. London, 1885. 

Saint Thomas's Hospital Reports. New Series. Edited by Dr. Seymour J. Sharkey and M. Francis 
Mason. Vol. XIV. London, MDCCCLXXXVI. 

Proceedings of the Medico-Chirurgical Society of Montreal for 1883-84-85. Published by the Society. 
Montreal, 1886. 

Transactions of the Obstetrical Society of London. Vol. XXVII. For the year 1885. With a list of 
Officers, Fellows, etc. London, 1886. 

Transactions of the Obstetrical Society of London. Vol. XXVII. For the year 1886. London, 1886. 

Medico-Chirurgical Transactions. Published by the Royal Medical and Chirurgical Society of Lon- 
don. Second Series. Volume the Fiftieth. London : Longmans, Green & Co., 1885. 

On Dermatitis Ferox. By J. L Milton, Senior Surgeon to St. John's Hospital for Diseases of the 
Skin. Edinburgh. 

Ovarian Abscess and Pyosalpinx. Pelvic Abscess. By Francis Imlach, M.D., Honorary Surgeon 
to the Liverpool Hospital for Women. Edinburgh, 1886. 

On the Commoner Accidents Attending Parturition ; their Immediate and Remote Effects. With 
Treatment. By William A. Duncan, M.D., M.R.C.P., F.R.C.S., Assistant Obstetric Physician to, 
and Lecturer on Operative Midwifery at, the Middlesex Hospital. London, 1886. 

On Extirpation of the Entire Uterus. By William A. Duncan, M.D., M.R.C.P. London, 1886. 

On the Causation and Nature of Hypertrophy of the Prostate. By Reginald Harrison, F.R.C.S., 
Surgeon to the Liverpool Royal Infirmary. 

An Introduction to the Pathology of Cancer and Tumor Formation. On Basis of Evolution. By 
W. Roger Williams, F.R.C.S., Surgeon to the Western General Dispensary, London. 



TO READERS AND CORRESPONDENTS. 5 

Ague; or, Intermittent Fever. By M. D. O'Connell, M.D., M.Ch., L.M., Surgeon-Major Medical 
Staff. Calcutta, 1885. 

De la Suture des Nerfs a Distance. Par le Dr. Georges Assaky, Ancien interne des hopitaux, 
Aide d'anatomie, Preparateur de medecine operatoire de la Faculte. Paris, 1886. 

Bibliotheque de Philosophie Contemporaine. Le Langage Interieur et les Diverges Formes de 
l'Aphasie. Par Gilbert Ballet, Professeur agrege a la Faculte de Medecine de Paris, Medecin des 
Hopitaux. Paris, 1886. 

Note sur les Paralysis Laryngees d'Origine Centrale. Par le Dr. A. Cartaz, ancien interne des 
hopitaux de Paris et de Lyon. Paris, 1885. 

Recherches Cliniques et Therapeutiques sur l'Epilepsie, l'Hysterie et l'ldiotie. Compte Eendu du 
Service des Epileptiques et des Enfants Idiots et Arrieres de Bicetre pendant l'Annee, 1884. Par 
Bourneville, Medicin de Bicetre Budor, Dubarry et Leflaive Internes du Service et P. Bricon, Docteur 
en Medecine. Vol. V. Paris, 1885. 

Manuel Pratique des Maladies des Fosses Nasales et de la Cavite Naso-Pharyngienne. Par le Dr. E. 
J. Moure, Professeur libre des Maladies du Larynx, des Oreilles et du Nez, Directeur de la Revue 
Mensuelle de Laryngologie, Otologie et Rhinologie, etc. Paris, 1886. 

Vorlesungen liber Orthopadische Chirurgie und Gelenk-Krankheiten. Von Dr. Lewis A. Sayre, 
Professor der Orthopa'disehen und Klinischen Chirurgie am Bellevue Hospital, und Consultirendem 
Chirurgen des Charity und des Elizabeth Hospitals in New York, etc. etc. Zweite sehr erweiterte 
Auflage. Von Dr. F. Dumont, Assistenzarzt der Chirurgischen Poliklinik zu Bern. Wiesbaden, 1886. 

Ueber den Werth und die Resultate der verschiedener Entfettungsmethoden. Von Sanitatssrath Dr. 
Jacques Mayer. Pract. Arzt in Karlsbad. Berlin, 1886. 

L'Ammazzatoio del sig. n. Macchi in Bosignano, Considerazoni Ulteriori, del D. A. Feroci. Pisa, 
1885. 

L'Ammazzatoio del sig. u. Macchi in Bosignano. Parere del D. A. Feroci. Pisa Nella Tipografia, 
Vannucchi, 1885. 

In Lezioni di Chinsura dell' Anno Clinico, 1883-81. Pisa, 1884. 

Die Alcune Malattie Dell'Apparecchio Orinario Moschile e Tenminile. Becordi Cliniche Statistici, 
del Prof. Pasquale Laydi. Pisa, 1885. 

Interno All' Utilita dei Purganti in Certes Forme di Dissenterio Cronica dalle Lezioni Cliniche. Del 
Professore Domenico Cappozi, Incaricato Dello Insign. Di Patologia Sp. Med. e Clinica Propedeutica 
nella Begia Universita degli Studi di Napoli (Estratto dal Medico Pratico Contemporaneo, 1885. Fasci- 
golo 4.o.). Napoli, 1885. 

Censimento dell Popotazione del Begno d' Italia al 31 Decembre, 1881. Relazione General e Con- 
fronti Internazionala. Eoma Tipografia Eredi Botta, 1885. 

Ministero dell' Interno il Colera in Italia Negli Anni 1884 e 1885. Boma Tipografia Elzerviriani nel 
Ministero delle Finanze, 1885. 

A Contribution to the Pathology of Hemianopsia of Central Origin (Cortex Hemianopsia) By E. C. 
Seguin, M.D., Clinical Professor of Diseases of the Mind and Nervous System in the College of Physi- 
cians and Surgeons, New York. 

The Mechanism of Indirect Fractures of the Skull. By Charles W. Dulles, M.D., Fellow of the 
College of Physicians of Philadelphia. 

Intubation of the Larynx, with History of Cases. By F. E. Waxham, M.D , Professor of Diseases 
of Children in the College of Physicians and Surgeons of Chicago, 1886. 

The Evolution of Surgery. By Dr. Joseph Eastman, Indianapolis. 

Reflex Irritation from Hypertrophy of Labia Minora. By Chas. L. Gwyn, M.D., Galveston, Texas, 
1886. 

Permanent Drainage for Ascites. By Augustus Caille, M.D. New York, 1886. 

The Production and Prevention of Perineal Lacerations during Labor. By Henry T. Byford, M.D., 
Physician and Surgeon to the Woman's Hospital, Chicago. Chicago, 1886. 

Ethics of Female Sterility. By A. Reeves Jackson, A.M., M.D., Professor of Gynecology in the 
College of Physicians and Surgeons of Chicago. 

Diseases of the Eye, occurring in Affections of the Kidney. By Wm. Oliver Moore, M.D., Professor 
of the Diseases of the Eye and Ear in the New York Post-Graduate Medical School. 

Water Supply of Cities and Villages. By A. Vanderveer, A.M., M.D. Albany, 1886. 

Esthetics of Medicine. By H. A. Cottell, M.D., Professor of Medical Chemistry and Microscopy in 
the University of Louisville, Ky. 1886. 

Boyleston Prize Essay, 1885. The Best Preliminary Education for the Study of Medicine. By Ed- 
ward S. Stevens, M.D., Lebanon, 0. 

General Atrophy of the Conducting Apparatus of the Ear (Proliferous Inflammation). By S. 0. 
Richey, M.D., Washington, D. C. 

Ulcer of the Stomach. A Lecture. By Prof. L. Oser, of Vienna, Austria. 

Circumscribed Peritoneal Dropsy, simulating Ovarian Dropsy. By H. P. C. Wilson, M.D., Surgeon 
to the Hospital for Women of Maryland. Baltimore, 1886. 



b TO READERS AND CORRESPONDENTS. 

Examination of the Auditory Organ of School Children. By Dr. Fried rick Bezold, Munich, 
New York. 

Results of Inquiries Conducted by the Health Department of the State Board of Health, Lunacy, and 
Charity, Relative to the Quality of Milk as produced in Massachusetts. 1886. 

Report of an Inspection of the Atlantic and Gulf Quarantines between the St. Lawrence and Rio 
Grande. By John H. Rauch, M.D., Secretary Illinois State Board of Health. Springfield, 1886. 

The Nervous Symptoms of so-called Lithsemia. By Landon Carter Gray, M.D., Professor of Ner- 
vous and Mental Diseases in the New York Polyclinic. Brooklyn, 1886. 

Two Cases of Laparo-Elytrotomy, with Remarks. By Charles Jewett, A.M., M.D., Professor of 
Obstetrics and Diseases of Children in the Long Island College Hospital, etc. 1885. 

The Influence of Sewerage and Water-supply, on the Death-rate in Cities. By Irwin F. Smith. 

What is Medicine ? Annual Address delivered before the American Academy of Medicine, at New 
York, October 28, 1885. By Albert L. Gihon, A.M., M.D., Medical Director U. S. Navy, President of 
the Academy. Philadelphia, 1886. 

Tetanus. Lecture delivered at the College of Physicians and Surgeons, Chicago. By N. Senn, M.D., 
Surgeon to Milwaukee Hospital. 1886. 

On Koch's Methods of Studying the Bacteria, with Special Beferences to the Bacteria causing Asiatic 
Cholera. By T. Mitchell Prtjdden, M.D., Director of the Laboratory of the Alumni Association of 
the College of Physicians and Surgeons, New York. 

The Early Physicians of Philadelphia and its Vicinity. An Address at the First Annual Meeting of 
the Association of Resident Physicians of the Pennsylvania Hospital, December 17, 1885. By James J. 
Levick, M.D. Philadelphia, 1886. 

Rundzeller Sarcom des Ohres. Von J. Orne Green, M.D., Boston. 

Two Rare Cases of Abdominal Injury. By J. A. Stucky, M.D., Lexington, Ky. New York, 1885. 

A Brief Synopsis of the Various Points Involved in the Coarse Examination of the Brain and Spinal 
Cord. By Francis X. Dercum, M.D., Pathologist to State Hospital for the Insane at Norristown. 
Norristown, 1886. 

Johns Hopkins University, Baltimore. Studies from the Biological Laboratory. Vol. III., No. 6, 
May, 1886. 

Transactions of the Michigan State Medical Society for the year 1885. No. 1, Vol. IX. Lansing, 
1885. 

Proceedings of the American Pharmaceutical Association, at the Thirty-third Annual Meeting, held 
at Pittsburg, Pa., September, 1885. Philadelphia, 1886. 

Report of the Board of Health of the City of Reading for the year 1885. 

Ninth Annual Report of the Board of Health of the State of New Jersey for 1885. Trenton, 1885. 

Report of the Illinois State Board of Health, Quarterly Meeting, Chicago, April 15-16, 1886. 

Report of the State Board of Health of Wisconsin, 1885. Madison, Wis., 1886. 

Report of the State Asylum for Insane Criminals, Auburn, N. Y., for the year ending September 30, 
1885. Auburn, N. Y., 1886. 

Report of the Butler Hospital for the Insane. Providence, 1886. 

Report of the Athens (Ohio) Asylum for the Insane, for the year 1885. Columbus, 1886. 

Report of the Trustees of the Massachusetts General Hospital and McLean Asylum, 1885. Boston, 
1886. 

Report of the Cincinnati Hospital, 1885. Cincinnati, 1886. 

Report of the Germantown Dispensary and Hospital. Philadelphia, 1886. 



CORRIGENDUM. 



Dr. Frank Donaldson, Jr., learns with regret that in his paper on "The Function of the Recurrent 
Laryngeal Nerve," in this number, he has unintentionally done injustice to Dr. Hooper. He is informed 
that the quotation from Dr. Hooper on page 94, "all our attempts to verify the observations have 
failed," does not refer to all the experiments made by Dr. Hooper, as he had supposed, but only to 
the last series. 



CONTENTS 



ORIGINAL COMMUNICATIONS. 

PAGE 

On Ulcerative Endocarditis. By Byrom Beamwell, M.D., F.R.C.P. 
(Edin.), Assistant Physician and late Pathologist to the Edinburgh 
Royal Infirmary; Lecturer on the Principles and Practice of Medicine 
and on Practical Medicine and Medical Diagnosis, in the Extra- 
Academical School of Medicine, Edinburgh ; formerly Physician to 
the Newcastle-on-Tyne Infirmary, etc. With a Report of Cultivation 
and Inoculation Experiments. By Mr. A. W. Hare, Assistant to the 
Professor of Surgery in the University of Edinburgh 17 

Scarlatinal Nephritis. By I. E. Atkinson, M.D., Professor of Thera- 
peutics and Materia Medica and Clinical Medicine in the University 
of Maryland 53 

Bacteriology. By W. Watson Cheyne, M.B., F.R.C.S., Assistant Sur- 
geon to King's College, Hospital, Surgeon to the Paddington Green 
Children's Hospital, etc. 66 

The Function of the Recurrent Laryngeal Nerve. From Experimental 
Studies in the Biological Laboratory of the Johns Hopkins University. 
By F. Donaldson, Jr., B.A., M.D., Chief of Clinic for Throat and 
Chest, University of Maryland, and late Scholar in Biology, Johns 
Hopkins University 93 

Notes Toward the Formationpf Clinical Groups of Tumors. By Jona- 
than Hutchinson, F.R.S., LL.D., Emeritus Professor of Surgery to 
the London Hospital . .103 

Chronic Hyperplasia of the Oral Mucosa, with Cornification of its Epi- 
thelium. By P. F. Harvey, M.D., Captain and Assistant Surgeon, 
U.S. A 110 

The Functions of the Membrana Tympani Illustrated by Disease. By 
Sir William B. Dalby F.R.C.S., Aural Surgeon to St. George's 
Hospital, London 121 

Micrococcus Pasteuri. By George M. Sternberg, M.D., Major and 
Surgeon, U. S. A 123 

A Case of Traumatic Neuritis of Thirty-five Years' Duration. Treat- 
ment by Repeated Nerve-section ; Subsequent History and Autopsy. 
By R. Osgood Mason, M.D., of New York . . . . . .131 



CONTENTS, 



The Surgery of the Pancreas, as Based Upon Experiments and Clinical 
Researches. By N. Senn, M.D., Attending Surgeon to the Milwaukee 
Hospital; Professor of the Principles and Practice of Surgery and 
Clinical Surgery in the College of Physicians and Surgeons, Chicago, 
Illinois 141 

Elephantiasis Arabum of the Labia Majora. A Case of Successful 
Operation by Excision. By Henry I. Raymond, A.M., M.D., Assist- 
ant Surgeon U. S. A 166 



REVIEWS. 

Recent Brain Surgery. 

1. Transactions of the American Surgical Association. Volume III. 
Edited by J. Ewing Mears, M.D. 

2. The Field and Limitation of the Operative Surgery of the Human 
Brain. By John B. Roberts, A.M., M.D., Prof, of Anatomy and 
Surgery in Philadelphia Polyclinic. 

3. Case of Cerebral Tumor. By A. Hughes Bennett, M.D., F.R.C.P. 
The Surgical Treatment, by Rickman J. Godlee, M.S., F.R.C.S. 
From Vol. LXVIII. of the Medico- Chirurgical Transactions. . . 169 

Recent Works on Diseases of the Larynx and Respiratory Passages. 

1. The Therapeutics of the Respiratory Passages. By Prosser James, 
M.D., Lecturer on Materia Medica at the London Hospital Medical 
College, etc. 

2. Laryngoscopy and Rhinoscopy. By Prosser James, M.D. 

3. Diseases of the Larynx. By Dr. J. Gottstein, Lecturer at the Uni- 
versity of Breslau. Translated and added to by P. McBride, M.D., 

of Edinburgh 173 

A Handbook on the Diseases of the Nervous System. By James Ross, 
M.D., F.R.C.P., LL.D., Senior Assistant Physician to the Manchester 
Royal Infirmary, etc 180 

The Management of Labor and of the Lying-in Period. A Guide for the 
Young Practitioner. By Henry G. Landis, A.M., M.D., Professor of 
Obstetrics and Diseases of Women in Starling Medical College, etc. . 183 

The Surgical Diseases of Children. By Edmund Owen, M.B., F.R.C.S., 
Surgeon to the Hospital for Sick Children, Great Ormond St., London 185 

How to Drain a House. Practical Information for Householders. By 
George E. Waring, Jr., M. Inst. C. E., Consulting Engineer for Sani- 
tary Drainage 188 

The Pathology and Etiology of Congenital Club-foot. By Robert 
William Parker, Surgeon to the East London Hospital for Children ; 
and Samuel George Shattock, Curator of the Museum, St. Thomas's 
Hospital 191 



CONTENTS. 



Moisture and Dryness; or the Analysis of Atmospheric Humidities in the 
United States. An Essay read before the American Climatological 
Association in 1884. By Charles Denison, A.M., M.D., Professor of 
Diseases of the Chest and of Climatology, University of Denver, etc. . 192 

A Manual of Human Physiology, including Histology and Microscopical 
Anatomy, with Special Reference to the Requirements of Practical 
Medicine. By Dr. L. Landois, Professor of Physiology and Director of 
the Physiological Institute, University of Griefswald. Translated from 
the Fourth German Edition, with Additions, by William Stirling, 
M.D., S.D., Regius Professor of the Institutes of Medicine or Physiology 
in the University of Aberdeen . . . . . . . .194 

Manual of the Diseases of Women, being a Concise and Systematic Ex- 
position of the Theory and Practice of Gynecology : for the Use of 
Students and Practitioners. By Charles H. May, M.D., late House 
Physician to Mount Sinai Hospital, New York, etc 195 

De la Suture des Nerfs a Distance. Par le Dr. George Assaky, Pre- 

parateur de Medecine Operatoire a la Faculte, etc. 
The Suture of Nerves after Loss of Substance. By Dr. George Assaky, 

etc 196 

The Principles and Practice of Surgery. By Frank Hastings Hamil- 
ton, A.M., M.D., LL.D 197 

Von Ziemssen's Handbook of General Therapeutics. Vol. IV. The 
Treatment of Disease by Climate, by Dr. Hermann Weber ; trans- 
lated by Heinrich Post, M.D., M.R.C.P. Lond., Physician to the 
German Hospital, London, etc; and General Balneotherapeutics, by 
Professor Otto Leichtenstern ; translated by John MacPher- 
son, M.D., Inspector-General of Hospitals (retired) .... 199 

The Landmarks of Snake Poison Literature, being a Review of the More 
Important Researches into the Nature of Snake Poisons. By Vincent 
Richards, F.R.C.S. Ed., etc., Civil Medical Officer of Goalundo, Ben- 
gal; late member of the Indian Snake Poison Commission . . . 201 

Health Reports. 

1. Seventh Annual Report of the State Board of Health of Illinois, 
with an Appendix Containing the Sanitary Publications of the Board 
during 1884. 

2. Proceedings and Addresses at the Sanitary Convention held at 
Ypsilanti, Michigan, June 30 and July 1, 1885. 

3. Ninth Report of the State Board of Health of Wisconsin for 1885 . 202 

Manuel Pratique des Maladies des Fosses Nasales et de la Cavite Naso- 
Pharyngienne. Par le Dr. E. J. Moure, Professeur libre des Maladies 
du Larynx, des Oreilles et du Nez; Directeur de la Revue Mensuelle 
de Laryngologie, Otologie et Rhinologie, etc 203 



10 CONTENTS. 



Clinical Studies on Diseases of the Eye, including those of the Conjunc- 
tiva, Cornea, Sclerotic, Iris, and Ciliary Body. By Dr. Ferdinand 
Ritter von Arlt, Professor of Ophthalmology in Vienna. Translated 
by Lyman Ware, M.D., of Chicago 204 



QUARTERLY SUMMARY 

OF THE 

PEOGEESS OF MEDICAL SCIENCE. 



ANATOMY 



Under the charge of George D. Thane, M.R.C.S. Eng. 

Prof essor of Anatomy at University College, London. 



The Lumbar Curve of the Spine in Several Races of Men. By Sir Wil- 
liam Turner 205 

On the Morphology of the Tarsus. By G. Baur 205 

On the Condition of the Umbilical Vein after Birth, and its Anastomoses 
with the Veins of the Abdominal Wall. By E. Wertheimer . . 206 

On the Rudiment of a Septal Gland in the Human Nose. By C. Gegen- 
baur .206 

On the Relation between the Calibre of the Bronchi and the Volume of 
the Lungs. By W. H. Browne and H. Stahel 207 

On Some Points in the Anatomy of the Thyroid Gland. By A. Strecke- 
isen 208 

On the Constitution of the Lateral Column of the Spinal Cord, and on 
the Origin of the Ascending Root of the Fifth Nerve. By Prof. W. 
Bechterew 209 



PHYSIOLOGY. 

Under the charge of Gerald F. Yeo, M.D. 

Professor of Physiology at King's College, London. 



Function of the Posterior Cerebral Commissure. By Darkschewitsch . 210 

Irritability of the Spinal Cord. By M. Schiff 210 

Visceral and Vasomotor Nerves. By Dr. W. H. Gaskell . . . 211 

Development of the Sympathetic Nerve. By Onodi .... 214 



CONTENTS. 11 



MATERIA MEDICA, THERAPEUTICS, AND 
PHARMACOLOGY. 

Under the charge of Roberts Bartholow, M.D., LL.D., 

Professor of Materia Medica, General Therapeutics, and Hygiene in Jefferson Medical College, Philadelphia. 



PAGE 

The Bark of Quebracho Blanco and its Active Principles. By MM. 
Charles Eloy and Henri Huchard 214 

Calomel in the Treatment of Hypertrophic Cirrhosis and other Affec- 
tions. By Sacharjin 218 

Urethan : its Physiological Actions, and Antagonism to Strychnine. By 
Prof. Coze 219 

Terpene in Chronic Bronchitis. By Dr. Rieu 220 

Action of Amyl Nitrite. By L. Schweinburg 220 

Physiological and Clinical Action of Grindelia Robusta. By Dr. Vasili 
Dobrokolowski 220 

Results of Administration of Thallin, and Caution as to its Physiological 
Effects. By Dr. Karst 221 



SURGERY. 



(IN EUROPE.) 

Under the charge of Frederick Treves, F.R.C.S., 

Surgeon to, and Lecturer on Anatomy at, the London Hospital. 



Recent Surgical Literature 222 

The Fate of Pathogenous Germs in the Body. By Dr. Ribbert . . 227 
Nerve Suturing. By Mr. Reginald Harrison, Dr. Koppeschaar, and 

Hoffmann 227 

Surgical Treatment of Empyema. By Dr. Maclaren .... 227 
Compression of the Innominate Artery. By Prof. Annandale . . 228 

On Rectal Exploration in Cases of Hip Disease. By Dr. Schmitz . . 228 
On the Treatment of Hip Dislocations Complicated by Fracture of the 

Neck of the Femur. By Dr. Wippermann 229 

Acute Myositis. By Prof. Scriba 229 

Aneurism of the Abdominal Aorta. By Dr. Liebrecht .... 229 
A New Method of Reducing Hernia. By Dr. Nikolaus .... 230 

Flat-foot. By Prof. Humphry 230 

Drainage of the Bladder. By Mr. Howlett 231 

On the Cause of Hypertrophy of the Prostate. By Mr. Reginald Harrison 231 
Tubercular Disease of the Genito-urinary Organs in the Male. By Dr. 

Steinthal 232 

Operations on the Stomach. By Dr. Hacher 232 

On the Treatment of Peritonitis by Laparotomy. By Prof. Studensky, 

Dr. Naumann, M. Chavasse, Dr. Valerani, and Dr. J. Mikulicz . . 233 



12 CONTENTS. 

(IN AMERICA.) 

Under the charge of R. J. Hall, M.D. 

Of New York. 



PAGE 

Tracheotomy for Pseudo-membranous Laryngitis. By Dr. Robert W. 
Lovett 234 

Intubation of the Larynx in Fifteen Cases of Diphtheritic Croup. By Dr. 
Dillon Brown 235 

Laparotomy in the Treatment of Penetrating Wounds and Visceral Inju- 
ries of the Abdomen. By Professor F. S. Dennis 235 

Permanent Drainage in Ascites. By Dr. Aug. G. Caille .... 236 

On Spontaneous Phlebacteriektasia of the Foot. By Dr. A. G. Gerster . 237 



OPHTHALMOLOGY. 

Under the charge of Charles Stedman Bull, A.M., M.D., 

Lecturer on Ophthalmology in the Bellevue Hospital Medical College, Surgeon to the New York Eye and Ear 

Infirmary. 



A New Operation for Congenital Ptosis and Paralytic Ptosis. By Panas . 238 

The Artificial Cornea. By Martin 239 

Sympathetic Keratitis following Destruction of an Eye from Injury. By 

Holland 239 

A Case of Sympathetic Inflammation Cured without Enucleation of the 

Fellow Eye. By Hoffmann 240 

The Etiology of Glaucoma. By Schoen 240 

Partial Embolism of the Inferior Division of the Central Retinal Artery 

associated with repeated previous attacks of Chorea. By Benson . 241 

On Changes in the Fundus of the Eye in Sepsis. By Boyer . . . 242 
Epilepsy with Optic Neuritis, Cured by Enucleation of the Wounded 

Eye. By Galezowski 242 

Acute Rheumatic Retrobulbar Neuritis. By Perlia 243 

The Insufficiency of the Power of Convergence. By Landolt . . . 243 
The more Modern Operations for Trichiasis. By Benson . . . 244 

Nerve-stretching — Badal's Operation. By Lagrange .... 245 
Paralyses of the Motor Nerves of the Eye, and their Treatment by the 

Bromohydrate of Pelletierine. By Galezowski 246 

Researches and Remarks upon Ocular Grafting or Transplantation. By 

Terrier 246 

The Infecting Germs Contained in Lachrymal Sac Abscesses, and their 

Relation to Antiseptics. By Sattler 246 

The Antiseptic Action of Cocaine, Corrosive Sublimate, and Chlorine 

Water upon the Secretions in Dacryocystitis, Tested by Inoculations of 

the Cornea. By Schmidt-Rimpler . 247 

Experiments on the Action of Bacteria in Operations on the Eye. By 

Knapp 248 

Skiascopy ; its Advantages and its Place in Ophthalmology. By Chibret 248 



CONTENTS. 13 



OTOLOGY. 



Under the charge of Charles H. Burnett, M.D., 

Professor of Otology in the Philadelphia Polyclinic and College for Graduates in Medicine, etc. 



PAGE 



Membranous Closure of the External Auditory Canal. By Hermann 
Bothholtz 249 

Foreign Bodies in the Air. By Hedinger 249 

Morbid Changes in the Bone in the Auditory Canal of Ancient Peruvian 
Skulls. By R. Virchow 250 

Fracture of the Handle of the Malleus by a Blow on the Ear. By Dr. A. 
Eitelberg 250 

Abscess of the Brain Caused by Otorrhoea ; Cured by an Operation. By 
Schede 251 

The Relation of the Chorda Tympani to the Perception of Taste in the 
Anterior Two-thirds of the Tongue. By Dr. Edward Schulte . . 251 

Rupture of both Membranse Tympanorum, and Concussion of both Laby- 
rinths. By Dr. Keeler 252 

Exfoliation of a Necrotic Cochlea, Containing the two Upper Whorls ; 
Healing of the Suppuration, with only Partial Loss of Hearing in the 
Affected Ear. By Dr. Joseph Gruber 253 



DISEASES OF THE LARYNX AND CONTIGUOUS 
STRUCTURES. 

Under the charge of J. Solis-Cohen, M.D., 

Professor of Diseases of the Throat and Chest, Philadelphia Polyclinic. 



Tuberculous Ulceration of the Mouth. By Dr. E. Clifford Beale . . 253 

Unusual Wound of the Soft Palate. By M. Pasteur .... 254 

Cylindroma of the Soft Palate. By Sir W. Mac Cormac .... 254 

Accessory Tonsil. By Jurasz 255 

Acute Tonsillitis and Rheumatism. By Mr. Fox and Dr. Easby . . 255 

Pemphigus of the Pharynx. By Dr. Charles E. Gooding . . . 255 

Cocaine to the Pharynx in Hydrophobia 255 

Mycosis of the Throat. By Dr. Henri Guinier 255 

Aneurism of the Left Internal Carotid Artery in its Extreme Upper 

Portion Rupturing into the Pharynx. By Prof. M. F. Coomes . . 255 
Lateral Pharyngotomy for Extirpation of Malignant Tumors in the Ton- 
sillar Region. By Prof. J. Mikulicz 256 

Neuroses of the Pharynx. By Dr. Th. Herring 256 

Stricture of the (Esophagus. By Dr. B. Ward Richardson and Sir Wm. 

Mac Cormac 257 



14 CONTENTS. 



PAGE 



Carcinoma of the (Esophagus. By Dr. T. S. K. Morton .... 257 

A New Nasal Speculum. By Dr. L. Katz 257 

(Esophagotomy. By Mr. Bennett May and Dr. T. M. Markoe . . 257 

Epistaxis. By Dr. Lavrand 258 

Coryza. By Rabow 258- 

Aluminium Acetico-tartaricum, and Aluminium Acetico-glycerinatum 
Siccum in Laryngitis, Pharyngitis, Chronic Rhinitis, and Ozaena. By 

Dr. Max SchaafTer 258 

Nasal Polypi. By Mr. Spencer Watson . . . . . . .259 

Hay Fever and Allied Affections. By Dr. Ziem and Prof. Bosworth . 259 
Nasal Reflexes. By Dr. Emil Gruening, Dr. Thos. A. McBride, Dr. Har- 
rison Allen, Dr. Abram Jacobi, and Theodore Hering . . . 260 
Adenoid Vegetations in the Nasopharyngeal Cavity. By Dr. Michael . 260 
Neoplasms of the Nasal Septum. By Dr. 0. Chiari .... 261 

Tuberculosis of the Larynx; Lactic Acid Treatment in the Larynx, 
Pharynx, and Nose, with Especial Reference to Tuberculosis of the 
Larynx. By Dr. Edmund Jelinek ....... 261 

Cornu Laryngeum. By Dr. A. Jurasz 262 

Fracture of the Larynx. By Dr. Perotti, Dr. Manby, and Dr. William 

Hunt 262 

Ecchondroses and Exostoses of the Larynx. By M. Henry Bertoye . 262 

Carcinoma of the Larynx. By Dr. W. Lubinsky 263 

Neuroses of the Larynx. By Dr. Treuvelot, Dr. Brebion, and Dr. Hering 264 
Spasm of the Larynx in Hydrophobic Tetanus. By Dr. Conrad Brunner 264 

Paralysis of the Larynx. By Dr. A. Cartaz 265 

Stricture of the Trachea. By Dr. J. Dreschfeld, Dr. Clougenheim, and 
A. Robin 265 



DERMATOLOGY. 

Under the charge of Louis A. Duhring, M.D. 

Professor of Dermatology in the University of Pennsylvania, 
AND 

Henry W. Stelwagon, M.D., 

Physician to the Philadelphia Dispensary for Skin Diseases. 



Therapeutic Use of Lanolin. By Lassar 26fr 

Dermatitis Ferox. By J. L. Milton 267 

Etiology of Alopecia Areata. By Max Joseph 268 

Resorcin in Acuminated Warts. By Caesar Bceck ..... 268 

Leucoderma Syphiliticum. By 0. Rosenthal 268 

Rhinoscleroma. By Prof. Kobner, Dr. Payne, Dr. Semon, and Janovsky 269 
Papayotin in Glosso-pathology. By Schwimmer ..... 270 

Delhi Boil. By J. Hickman 271 

Hereditary Predisposition to Bleb-formation. By Max Joseph . . 272 
The Treatment of Eczema and Impetigo in Children by the Internal Use 
of Chrysarobin. By Stocquart 272 



CONTENTS. 15 



MIDWIFERY. 



Under the charge of Francis H. Champneys, M.B.. F.K.C.P., 

Obstetric Physician to St. George's Hospital. 



PAGE 



On the Lower Segment of the Uterus. By Hofmeier .... 273 

Parturition during Hypnotism. By Pritzl 274 

On the Form of the Uterine Muscle-curve and on Peristalsis of the Human 

Uterus. By Schatz 275 

Quinine as an Oxytocic. By J. A. Coe and J. E. Allen .... 275 
On the Possibility of Perceiving the Cardiac Impulse of the Intrauterine 

Foetus when the Latter is Extended. By Fischel .... 276 

Some Eecent Considerations on the Prefcetal Dilatation of the Vulva, 
accompanied by a Study on the Formation and Rupture of the Sac of 

the Liquor Amnii. By Dr. Leon Dumas 276 

Dropsy and Albuminuria in Pregnancy. By Leyden .... 282 
The Advisability of Inducing Abortion in Cases of so-called Uncontroll- 
able Vomiting of Pregnancy. By Dr. O. W. Hoe 282 

Extrauterine Gestation ; Death from Rupture 283 

A Case of Extrauterine Pregnancy. By Dr. G. R. Robertson . . . 284 
On the Value of Braxton Hicks's Method of Combined Version in Cases 

of Induced Premature Labor. By Fehling 285 

Splitting of the whole Urethra during Labor. By Krukenberg . . 285 

Rupture of the Uterus 286 

A Case of Csesarean Section, with Remarks on the Use of Silver Sutures. 

By Schauta 286 

Unsuccessful Case of Cesarean Section after the Method of Sanger and 

Leopold. By Minister 288 

Porro's Operation ; Survival of Mother and Child 288 

When Should the Umbilical Cord be Tied? 289 

The Etiology of Ischuria during the Post-partum Period, and after the 
Removal or Tapping of Large Abdominal Tumors, with some Remarks 
on Micturition in General. By Schwarz ...... 289 

The Temperature of the Mammary Gland during the Puerperium. By 

Negri 291 

The Prophylaxis of Pendulous Abdomen in Women. By Czerny . . 292 
The Medico-legal Importance of Hsematoma of the Sterno-mastoid in 
Newborn Children. By Kiistner 292 



GYNECOLOGY. 



Shock, its Relation to Diseases of the Organs of Circulation in Abdominal 
Tumors. By Hofmeier 293 

Diabetes in Relation to the Uterine Life, Menstruation, and Pregnancy. 
By Dr. Lecorche 295 



16 CONTENTS. 

PAGE 

The Significance and Diagnosis of Gonorrhoea in Women. By Lomer . 297 
On the Palpation of Pelvic Organs. By Schultze 298 



MEDICAL JURISPRUDENCE AND TOXICOLOGY. 

Under the charge of Matthew Hay, M.D., 

Professor of Medical Jurisprudence, University of Aberdeen. 



Lung Test in Infanticide. By Sommer ....... 300 

State of the Pupil after Death. By Dr. J. N. Marshall . . . .301 

Different Putrefactive Appearances in the Corpses of Two Individuals 

who Died under exactly similar Circumstances. By Meyer . . . 301 
Sulphuretted Hydrogen. By Brouardel and Loye ..... 302 
Ptomaines. By Lehnert, Oeffmger, Salkowski, Lepine, Guerin, Hager, 

and Bocklisch 303 

Poisoning by Cheese. By Vaughan 303 

Alleged Homicide by Chloroform Poisoning 303 

Alleged Poisoning by Colchicine. By Brouardel ..... 304 
The Results of Recent Investigations of Pork. By Dr. Herrmann Eulen- 

berg 304 



THE 

AMERICAN JOURNAL 

OF THE MEDICAL SCIENCES 

JULY, 1886. 



ON ULCEEATIVE ENDOCARDITIS. 
By Byrom Bramwell, M.D., F.R.C.P. (Edin.), 

ASSISTANT PHYSICIAN AND LATE PATHOLOGIST TO THE EDINBURGH HOYAL INFIRMARY ; LECTURER ON THE 

PRINCIPLES AND PRACTICE OF MEDICINE AND ON PRACTICAL MEDICINE AND MEDICAL DIAGNOSIS 

IN THE EXTRA-ACADEMICAL SCHOOL OF MEDICINE, EDINBURGH ; FORMERLY PHYSICIAN 

TO THE NEWCASTLE-ON-TYNE INFIRMARY, ETC. 

WITH A REPORT OF CULTIVATION AND INOCULATION EXPERIMENTS. 

By Mr. A. W. Hare, 

ASSISTANT TO THE PROFESSOR OF SURGERY IN THE UNIVERSITY OF EDINBURGH. 

In addition to the cases of simple endocarditis which were analyzed 
in my paper on right-sided endocarditis in the April number of this 
journal, there were 14 cases which seemed to belong to the ulcerative 
or malignant form of the disease. I am doubtful whether two of these 
should be included, for although the character of the vegetations, their 
luxuriance and the presence of micrococci, was suggestive of the malig- 
nant variety, the other pathological features — notably the condition of 
the spleen — seemed in favor of the simple form of the disease. 

The frequency with which the different valves were affected was as 
follows: Aortic valve alone in 7 cases (in one of these there appeared 
to be the remains of old vegetations on the mitral valve ) ; aortic and 
mitral in combination in 6 cases ; aortic and tricuspid in combination in 
1 case. The aortic valve was, therefore, affected either alone or in com- 
bination in 14 cases = 100 per cent. ; the mitral in 6 cases = 42.85 per 
cent. ; the tricuspid in 1 case = 7.14 per cent. 

These results appear to be exceptional ; for Osier, in his analysis of 
more than 200 cases, found that " the aortic and mitral valves were 

NO. CLXXXIII. — JULY, 1886. 2 



18 



EAMWELL, ULCERATIVE ENDOCARDITIS. 



affected together in 41 cases ; the aortic alone in 53 ; the mitral alone in 
77; the tricuspid in 19; the pulmonary valves in 15; and the heart- 



Fig. 1. 







V-7 ' 




Interior of the left ventricle, showing extensive ulcerative endocarditis of the anterior coronary 
segment in the case of A. Blythe. 

The letter A points to a large ragged perforation in the valve segment. 

The aortic valve segments were jierforated or ulcerated through in 8, 
and the mitral in 3 cases. Aneurisms were present on the mitral valve 



Gulstonian Lectures on Malignant Endocarditis, Lancet, March 7, 1885, p. 417. 



BRAMWELL, ULCERATIVE ENDOCARDITIS. 



19 



in 1 case ; on the aortic segments in several of the cases in which the 
valve segments were perforated ; and at the root of the aorta (in or 
immediately above the sinuses of Valsalva) in 2 cases. In 1 case there 
was an aneurism of the left ulnar artery, which had ruptured into 
the tissues of the forearm, and formed a large false sac. Rupture of the 
chordce tendinece was met with in 1 case. Vegetations were present on the 
endocardium in several instances (though they are only noted in the ledger 
as having been present in 1 case) ; there were also vegetations at the 



Fig. 2. 




-m iff i 



The interior of the right auricle, the tricuspid valve, and part of the interior of the right ventricle, in 
the case of A. Blythe, showing a small aneurism (C) which sprang from the bottom of the left coronary 
sinus of Valsalva, and projected into the cavity of the left auricle, at the level of the attachment of the 
tricuspid valve. 



root of the aorta in 3 cases. In several instances, the vegetations at the 
root of the aorta, and perforation of the anterior flap of the mitral valve, 
were clearly due to the friction and impaction of long, pendulous vegeta- 
tions attached to the aortic segments. Chronic valvulitis was certainly 
present in 7, and probably in at least one or two other cases. 

The naked-eye appearances which the lesion presented were very 
various; some of them are shown in Figs. 1, 2, 3, 4, and 5. 



20 



BRAMWELL, ULCERATIVE ENDOCARDITIS. 



In two cases the vegetations were of a greenish-yellow color, an 
appearance which Osier has also described. 1 

The size of the heart is not noted in 1 case, in 2 it was normal, and 
in the remaining 11 cases the organ was enlarged, often to a very con- 
siderable decree. 



Fig. 3. 



E 



J\: 



A 





The aortic valve in a ease of ulcerative endocarditis, showing luxuriant flat vegetations on 
two of the segments. 

The more important associated pathological changes were as follows : 
(1) Spleen. — The condition of the spleen was noted in all but one 
case f the organ was invariably enlarged. In one case its structure 
appeared normal to the naked eye ; in two cases it was dark colored, 
firm, and congested, resembling the ordinary spleen of old-standing 
mitral disease ; in one case it appeared to be waxy ; in all the other 
instances it was soft, pulpy, and fever-like. In two cases ordinary hem- 
orrhagic infarcts are stated to have been present in the spleen, but the 
number of cases in which this lesion occurred was probably greater, for 
I have a strong impression that the presence of infarcts has in more than 
one case been omitted by the clinical clerk in transcribing the notes. 



1 Gulstonian Lectures on Malignant Endocarditis, Medical News, March 21, 1885, p. 310. 

2 In the case in which the spleen was not examined, "permission " was strictly limited to the cavity 
of the thorax. 



BRAMWELL, ULCERATIVE ENDOCARDITIS. 21 

In one case the spleen was in a state of commencing suppuration, 
innumerable small infective emboli being scattered throughout its 
substance. 

(2) Lungs. — Acute croupous pneumonia was certainly present in 3, 
and probably in 7 of the 14 cases ; in 1 instance both lungs were 



Fig. 4. 



A 



\ 




Aortic valve in a case of ulcerative endocarditis, showing heaped-up masses of moderately firm 
vegetations on the intercoronary and left coronary segments, both of which were perforated in their 
centres. 



affected with well-marked gray hepatization ; in 2 cases there was well- 
marked red hepatization, in 1 both lungs being affected, and in the other 
the left only involved ; in 4 cases both lungs were affected with oedema 
and congestion, which seemed to be pneumonic. 

In 3 cases oedema and congestion of a simple (non-pneumonic) kind 
were present ; in 1 there was marked brown induration ; in 1 marked 
emphysema ; in 1 ordinary hemorrhagic infarcts and patches of pulmo- 
nary apoplexy ; and in 1 case empyema with compression of the right 
lung, and recent pleurisy on the opposite side. 



99 



(3) Kidneys. — In 1 case the condition of the kidney was not ascer- 
tained ; in 5 cases the weight was normal ; in the remaining 8 cases 
the kidneys were enlarged, in some instances very markedly so. Ordi- 
nary hemorrhagic infarcts were present in 3 cases ; in 1 instance both 
kidneys were studded with septic infarcts and miliary abscesses ; in 1 
case many small ecchymoses, indicative of minute microscopical infarc- 
tions, were scattered throughout the cortex. In 2 cases the usual appear- 
ances of acute (non-suppurative) nephritis were present. 



Fig. 5 







m ■ 



\ 



imp 




Aortic valve in a case of ulcerative endocarditis, showing extensive ulceration and a large stalactite- 
looking vegetation (B) projecting from the left coronary cusp. Some small vegetations (A) are present 
at the base of the aorta, and on the wall of the ventricle, just below the aortic orifice. 



(4) Nerve Centreh. — In 8 cases the condition of the nerve centres 
was not ascertained. In 2 of the remaining 6 cases, there was well- 
marked cerebral meningitis ; in 1 of these cases the left middle cerebral 
artery was plugged with a recent infarct ; the Island of Reil was in a 



BEAMWELL, ULCEEATIVE ENDOCARDITIS. 23 

state of commencing softening, and there were numerous small puncti- 
form ecchymoses in the gray matter of each hemisphere ; in the other 
case, the membranes of the spinal cord were also in a state of commencing 
inflammation. In a third case, basilar meningitis was just commencing ; 
in a fourth, the membranes were adherent (the result of old disease) 
over the left ascending parietal and frontal convolutions. 

In 4 of the 6 cases in which the nerve centres were examined there 
were small hemorrhages in the retinae. 

(5) Skin and Cutaneous Cellular Tissue. — Punctiform ecchymoses 
and purpuric spots were noted as having been present in 3 cases, but I feel 
certain that they were more frequently observed. In 1 case, in which 
there was no croupous pneumonia, an herpetic eruption was present on 
the lips. In 6 cases the feet and legs were cedematous, and in 3 of these 
cases the oedema was great. 

(6) Liver, Intestine, Uterus. — In no case were miliary abscesses 
or infarcts found in the liver; in several instances the organ presented 
the ordinary appearances due to chronic venous engorgement ; in 1 case 
there had evidently been previous syphilitic hepatitis ; and in 1 case 
there was hypertrophic cirrhosis. 

In 3 instances at least (I think the number was greater) punctiform 
ecchymoses and small hemorrhages were present on the gastro-intestinal 
mucous membrane. In one case, the uterus was enlarged, the patient 
having been prematurely confined shortly before her admission to hospi- 
tal. A rough, granular-looking mass, the remains apparently of a portion 
of placenta, projected into the uterine cavity ; and there was an extra- 
vasation of blood about the size of a bean on the serous surface of the 
organ; notwithstanding these suggestive appearances, micrococci were 
not detected in the tissues of the uterus. 

(7) The Presence of Microorganisms in the Vegetations and 
Tissues. — In 3 instances the cardiac vegetations were not examined for 
microorganisms; in all the remaining 11 cases, microorganisms were 
found. In every instance, the organism was a micrococcus of small size 
which was either scattered through the substance and on the surface of 
the vegetation, or collected on the surface in round masses ; in no case 
were encapsuled masses of micrococci observed ; in 6 cases, the vegeta- 
tions were literally teeming with micrococci. 

Method of Staining. — Gram's method w r as in all instances em- 
ployed, methyl -violet, prepared according to Ehrlich's method (as 
recommended by Dr. M. Afanassiew, in the Edinburgh Medical Journal 
for February, 1885), being, as a rule, substituted for gentian-violet. 

In the examination of large sections of delicate and fragile tissue, 
such as the brain and spleen, the following modification of the usual 
method of carrying out Gram's process was employed, and will, I think, 
be found an improvement. It enables the section to be manipulated 



24 BRAMWELL, ULCERATIVE ENDOCARDITIS. 

with much greater freedom, and prevents the tearing and breaking of 
the tissue, which in my hands so frequently occur in the process of 
transferring a large and delicate section from the " lifter " and spreading 
it out on the slide preparatory to the final mounting. It also enables 
one to regulate with greater precision and accuracy, than is, I think, 
possible by the ordinary Gram's method, the washing out of the coloring 
matter from the tissues by the absolute alcohol and oil of cloves respec- 
tively ; finally, it has yielded in my hands more permanent preparations 
than the ordinary method. 

The process is as follows : 

The section having been (1) stained with methyl- violet ; (2) washed 
for a second or two in distilled water; (3) immersed for two or three 
minutes in a solution of iodine in iodide of potassium ; and (4) again 
washed in distilled water, as in the ordinary Gram's method; is (5) 
placed in a watch-glass containing absolute alcohol until the greater 
part of the coloring matter is washed out, but the decolorization should 
not be carried so far as in the ordinary method; (6) the section is then 
placed for a minute or two in a solution of eosine, from which (7) it is 
transferred to a basin of distilled water, where it may remain without 
injury for two or three hours — a great convenience to the operator. 
(8) The section is then floated on to, and carefully spread out on, a 
glass slide, as in the ordinary method of mounting large microscopical 
sections of delicate tissue. (9) It is next treated, while on the slide, 
with successive doses of absolute alcohol, until it is completely dehy- 
drated and sufficiently decolorized. In the case of very thin sections, 
which have been already pretty well decolorized, one or two doses of 
absolute alcohol dropped from a bottle on to the slide, and allowed to 
flow over the specimen, are usually sufficient. (10) The excess of 
alcohol is allowed to flow off the section, the slide being inclined to one 
side to facilitate drainage ; the slide round the margins of the section is 
carefully dried with the finger or a piece of fine cambric ; and (11) ivliile 
the section is still moist, a small quantity of oil of cloves is dropped on to 
the slide at one side of the section ; the slide is then inclined to the oppo- 
site side and the oil of cloves allowed to flow under the section, the 
preparation being supported in position by the point of a needle placed 
on the edge opposite to that from which the oil of cloves is flowing; the 
section may, of course, be held in position by the needle being placed 
through it at the side from ivhich the oil of cloves is running, but this I 
find is more likely to produce tearing in the case of very delicate tissues, 
such as brain and spinal cord. When the preparation is thoroughly 
cleared — it must be perfectly transparent — the slide is still further 
inclined, and the oil of cloves carefully wiped away from the edge of the 
section. (12) One or two large drops of zylol balsam are then placed 



BKAMWELL, ULCERATIVE ENDOCARDITIS. 25 

on the section (the amount of balsam must, of course, be varied with the 
size of the section) and the cover-glass is placed in position. 

A little practice will enable the oj)erator to manipulate the section 
on the slide with great facility, and to determine the amount of absolute 
alcohol and oil of cloves which is required. Specimens which are pro- 
perly prepared in this way retain their color ; the micrococci in some 
of my sectious, which were mounted a year ago, are still quite as 
brightly stained as when the preparations were first made. To insure 
permanency, each step in the process must he thoroughly carried out — the 
water in the section must be completely removed by the absolute alcohol 
— the alcohol must be thoroughly removed by the oil of cloves. If the 
section is not quite transparent after being treated with oil of cloves, it 
must be again treated with alcohol and again cleared — any excess of oil 
of cloves must be drained away by inclining the slide — and the amount 
of zylol balsam placed on the section must be more than is required for 
the mere mounting of the preparation, in order to drive out any oil of 
cloves which still remains in the section. 

After mounting, the preparation should be placed aside on a flat sur- 
face, any balsam which exudes being absorbed by small pieces of blot- 
ting paper placed round the margins of the cover-glass. After a day or 
two a small weight may be placed on the cover-glass ; but if this is done, 
care must be taken that the weight is not so heavy as to squeeze out or 
destroy the continuity of the sections. Heavier weights may from time 
to time be substituted ; the excess of balsam is in this way gradually re- 
moved, and a preparation finally obtained which is quite flat and free 
from wrinkles, and the whole of which can be examined with high mag- 
nifying powers. 

The time and labor required for histological investigations of this 
description are very great, and I have not attempted to make an exhaus- 
tive examination of all the peripheral organs in every case. In one 
case, however, in which the clinical symptoms were of the " pysemic 
type," and in which infective emboli were scattered in extraordinary 
numbers throughout the body, a thorough examination of all the organs 
was made. 

The clinical history of this case was as follows : 

Case. Robert Hardie, ast. thirty-four, was admitted to the Edin- 
burgh Royal Infirmary, under the care of Professor Annandale (to whom 
I am indebted for the clinical history of the case), on October 18, 1884, 
suffering from a urethral stricture and perineal abscess. 

The abscess was evacuated with proper precautions, on the day of ad- 
mission, and soon healed without febrile disturbance or other untoward 
symptoms. 

On Nov. 10th, the stricture was divided internally by Maisonneuve's 
method; the operation was followed by ups and downs in temperature, 



26 



BRAMWELL, ULCERATIVE ENDOCARDITIS. 



albuminuria, well-marked cardiac murmurs, and symptoms of cerebral 
meningitis. 




On Nov. 24th, the patient died. The post-mortem examination was 
made forty-eight hours after death, the abdomen being very slightly 
green at its lower part from commencing decomposition. There were no 
internal signs of putrefaction. There was no inflammatory lesion in the 



BRAMWELL, ULCERATIVE ENDOCARDITIS. 



27 



position of the perineal abscess ; and the urethra, except that a band of 
mucous membrane extended longitudinally along it at the seat of the 
stricture, appeared to be healthy. 

The naked-eye lesions which were found, were as follows : 

Heart : Aortic valve, all segments covered with very soft and luxuriant 

vegetations, the intercoronary segment ulcerated through, cone-diameter 

1.05; mitral valve healthy, cone-diameter 1.7 ; tricuspid valve healthy, 

cone-diameter 2; pulmonary valve healthy, cone-diameter 1.25; weight 



Fig. 7. 



B 



D 



D 







7^ 



Ife'S^- [ &, %5-.\ -r *~>f ' ^--'--s^ 




Camera lucida drawing of a section of the skin in ulcerative endocarditis, showing numerous masses 
of micrococci. Stained with methyl-violet and eosine, and mounted in zylol balsam. X Hartnack, 
objective 4; ocular 3 ; tube out ; and drawing reduced from 7 to 5 inches. The section was made through 
a purpuric patch and small abscess in the subcutaneous cellular tissue. A, free surface of the skin, 
which always contains organisms, and is consequently deeply stained of a blue color. B, points to the 
purpuric patch ; the cuticle is separated from the cutis (D, D,), which contains large masses of micro- 
cocci. 0, small abscess in the subcutaneous tissue ; numerous masses of micrococci (E) are seen in the 
wall of the abscess and in the surrounding tissue. 



of heart 9^- ozs. ; left ventricle 4 in. long, wall f in. ; right ventricle, 
length 3^-, wall ^. Spleen : 1 lb. 1 oz. ; very soft, of a rusty brown 
color ; in places yellow and apparently in a state of commencing sup- 
puration. Kidneys weigh 8 ozs. ; numerous small projecting abscesses 
on the surface surrounded by a ring of softening and congestion ; on 
section many streaks of inflammation extending through the cones to the 
cortex, and forming large wedge-shaped inflammatory lesions, in the 
midst of which the small abscess points, previously described, were sit- 



28 BRAMWELL, ULCERATIVE ENDOCARDITIS. 

Fig. 8. Fig. 9. 






I$imm 



41;'.-. / " !&* :*& : T%- 

v. .$&*•• 

Fig. 8 — Camera lucida drawing of a minute portion of a cardiac vegetation in ulcerative endocarditis, 
showing enormous numbers of micrococci, in masses (d) and scattered throughout the tissue. Stained 
with methyl-violet and eosine, and mounted in zylol balsam. X Hartnack, objective 9 : ocular 3 
tube out. 

c, free surface of the vegetation. 

Note. — To see the individual micrococci, the drawing should be held about six inches from the eye. 

Fig. 9. — Camera lucida drawing of a section of a papilla of the skin in ulcerative endocarditis, 
showing micrococci in clusters and scattered. Stained with methyl-violet and eosine, and mounted in 
zylol balsam. < Hartnack, objective 9 ; ocular 3 ; tube out. 

Note. — To see the individual micrococci, this drawing should be held about six inches from the eye. 

At a the micrococci are only represented ; at b the cells of the tissue (pus cells ?) have been drawn in. 








<^> 



Camera lucida drawing of a section of the choroid coat of the eyeball in ulcerative endocarditis, 
showing micrococci in the midst of pus cells. Stained with methyl-violet and eosine, and mounted in 
zylol balsam. X Hartnack, objective 9 ; ocular 3 ; tube out. 

a, free surface of the choroid from which the retina has been detached ; b, deeper layer of the 
choroid, containing stellate pigment cells ; c, collection of pus cells, in the midst of which numerous 
micrococci (d, d) are situated. 

Note. — To see the individual micrococci, the drawing should be held about six inches from the eye. 



BEAMWELL, ULCERATIVE ENDOCARDITIS. 



29 



uated ; weight: right 8 ozs., left 9 ozs. Lungs: a few old adhesions at 
both apices, very congested, oedematous and friable ; commencing pneu- 
monia ; weight: right 1 lb. 13 ozs., left 1 lb. 10 ozs. Brain: here and 
over the vertex, more especially at the top of the left frontal lobe, also 
over the base, numerous small punctiform ecchymoses and patches of in- 
creased vascularity in the membranes ; embolism of middle cerebral 
artery, commencing softening of the Island of Reil ; punctiform hemor- 
rhages here and there in the gray matter of the hemispheres ; weight, 3 
lbs. 5 ozs. Two or three small hemorrhages in each retina. Skin : Purpuric 

Fig. 11. 




Camera lucida drawing of a section of the superficial layer of the gray matter of the brain in 
ulcerative endocarditis, showing an artery which contains micrococci. Stained with methyl-violet 
and eosine, and mounted in zylol balsam. X Hartnack, objective 9 ; ocular 3 ; tube out. 

a, b, corpuscles of the neuroglia and small nerve cells ; c, artery, the walls of which are thickened ; 
the vessel is filled with red blood-corpuscles, and contains numerous micrococci which have been drawn 
rather larger than they are in the actual specimen, in order that they may show in the woodcut ; there 
are also some micrococci in the arterial coats ; d, lymphatic space surrounding the vessel. 



spots on the fiugers, small abscess on left forearm. Liver : 4 lbs. 3 ozs., 
fatty. Urethra, which had been divided by internal cutting operation for 
stricture, free from any inflammatory condition; a ridge of mucous 
membrane seemed to extend along the canal for some distance. Some 
inflammatory swelling of left testis, but no distinct abscess. 

Portions of the cardiac vegetations, spleen and kidneys, were placed 
in clean glass-stoppered bottles and immediately sent to Mr. Hare, and 
formed the material with which the first series of his cultivation and 
inoculation experiments were made. (See Mr. Hare's report, page 44.) 

Portions of all the tissues and organs were hardened both in absolute 
alcohol and in Miiller's fluid. On subsequent microscopical examination, 



30 



BEAMWELL, ULCERATIVE ENDOCARDITIS. 



micrococci were found in immense numbers in the cardiac vegetations, 
kidneys, membranes of the brain, cortex of the brain, choroid coat of 

Fig. 12. 



\ 

\ 



S'Uf%, 



<**\ 



HSr/m^r. 



P> 













> ' v '-; '• ■ ^>zj a :•<!.-- p/# y ■ ■■..>■, 4.-, 



K 



JK 



■>•:'' g V\ 7 

I 

V.' 7> 






7 r/ 



^ ! 



a// 



)fi '■! \k fi ] 



Camera lucida drawing of a section through the membranes of the brain in ulcerative endocarditis, 
showing numerous collections of micrococci in the midst of pus cells and in a vein. Stained with 
methyl-violet and eosine, and mounted in zylol balsam. X Hartnack, objective 9 ; ocular 3 ; tube out ; 
drawing afterward reduced from 6 to 4% inches. 

A, free surface of the portion of the membranes dipping down between two convolutions ; B, large 
artery at the bottom of the sulcus ; O, vein containing numerous micrococci ; D, mass of micrococci ; 
E, pus cells, in the midst of which there are numerous micrococci. 



the eye, skin, and testis. I failed to detect micrococci in the infarction 
which plugged the left middle cerebral artery, and in the liver. 



BRAMWELL, ULCERATIVE ENDOCARDITIS. 
Fig. 13 



31 







Camera lucida drawing of a section of the cortex of the brain in ulcerative endocarditis, showing 
a patch of cerebritis, and a large mass of micrococci in the adjacent brain-tissue Stained with 
methyl-violet and eosine, and mounted in zylol balsam. X Hartnack, objective 8 ; ocular 3 ; tube out. 

d, The portion of the gray matter affected with acute cerebritis ; b, healthy portion of gray matter 
containing pyramidal nerve cells, the neuroglial basis is not shown in the drawing ; c, transversely 
divided vessel ; e, mass of micrococci extravasated around a small vessel. 

Fig. 14. 




Camera lucida drawing of a section of the gray matter of the brain in ulcerative endocarditis, 
showing a small vessel (f) plugged with micrococci, and large pyramidal nerve-cells (e). Stained 
with methyl-violet and eosine, and mounted in zylol balsam. X Hartnack, objective 9 ; ocular 3 ; 
tube out. 



32 BRAMWELL, ULCERATIVE ENDOCARDITIS 



Fig. 1, 








Camera lucida drawing of a section of the gray matter of the brain in ulcerative endocarditis, 
showing a bloodvessel plugged with micrococci, and micrococci in the adjacent brain-substance. 
Stained with methyl-violet and eosine, and mounted in zylol balsam. X Hartnack, objective 9 ; 
ocular 3 ; tube out. 

a, Small pyramidal nerve cell ; b, capillary vessel plugged with micrococci ; c, a larger vessel (from 
which the capillary springs), also plugged with micrococci ; d, micrococci in the brain-substance. 

Fig. 16. 











Camera lucida drawing of a section of the cortex of the kidney in ulcerative endocarditis, showing 
three Malpighian tufts, the vessels of which are plugged with micrococci. Stained with methyl-violet 
and eosine, and mounted in zylol balsam. X Hartnack, objective 4; ocular 3 ; tube out. 

a, Vessel proceeding to the Malpighian uft at the top of the drawing, stuffed with micrococci ; h, a 
mass of micrococci in the iutertubular tissue, which is infiltrated with round cells not shown in the 
drawing; o, transversely divided renal tubule ; d, intertubular tissue. 



BKAMWELL, ULCERATIVE ENDOCARDITIS. 33 

Fig. 17. 




iff-'- ',•,?? >:i=»TO ■»* i # '4^ ■ • - "/ :,."# 






'tU 












U\ 



Ml 



€ 



€*|k 



w l S£) 


















^?M 




« « / 






Camera lucida drawing of a section through the cortex of the kidney in ulcerative endocarditis, 
showing numerous masses of micrococci stained with methyl-violet and eosine ; and mounted in zylol 
balsam. X Hartnack, objective 4 ; ocular 3 ; tube out; and drawing reduced from 7% to 6 inches. 
Plugs of micrococci, represented as black masses, fill the small vessels, and masses of micrococci are 
situated in the large veins. The intertubular connective tissue is much increased and infiltrated with 
round cells, which are not represented in the drawing. 

a, free surface of the capsule ; b, b, transversely divided renal tubules ; c, inflamed Malpighian tuft ; 
d, empty Malpighian capsule ; e, large artery longitudinally divided ; /, longitudinally divided vein 
containing micrococci in masses ; g, g, g, masses and plugs of micrococci. 
NO. CLXXXIII.— -JULY, 1886. 3 



34 



BKAMWELL, ULCERATIVE ENDOCARDITIS. 



The accompanying figures, which are exact photographic reproductions 
of camera lucida drawings made by myself, show the appearance which 
sections of the different organs presented, and render any further descrip- 
tion than that which is attached to the woodcuts, unnecessary. 

Micrococci have been drawn rather larger than the actual size, in 
order that they might be distinctly seen in the woodcuts. The mag- 
nifying power was, as a rule, a No. 9 immersion, Hartnack, eye-piece 
No. 3, and tube drawn out. 



Fig. J! 



Fig. 10. 



it ; ' #i i \))\ i mil i 









v; i 



8LV* 



m^ 



, 



r--y "n-Kii/'U V--i''"'i*- ■-•"^i^ -W 







v> 



Fig. 18. — Camera lucida drawing of a longitudinal section through the pyramidal portion of the 
kidney in ulcerative endocarditis, showing masses of micrococci. Stained with methyl-violet and eosine, 
and mounted in zylol balsam. X Hartnack, objective 4 ; ocular 3 ; tube out. 

m m, micrococci masses. 

Fig. 19. — Camera lucida drawing of a longitudinal section through the pyramidal portion of the 
kidney in ulcerative endocarditis, showing three renal tubules, the central one containing micrococci (m). 
Stained with methyl-violet and eosine, and mounted in zylol balsam. X Hartnack, objective 9 ; ocular 3 ; 
tube out. 



The frequent association of acute croupous 'pneumonia with ulcerative 
endocarditis is of great interest from an etiological point of view, as 
Osier has so forcibly pointed out in his admirable Gulstonian Lectures. 
In two of the three cases in this series, in which well-marked acute 
croupous pneumonia was present, I detected micrococci in the exudation 
filling the air-cells of the lung, but I failed to satisfy myself that they 
were identical with the micrococci in the cardiac vegetations. The 



BEAMWELL, ULCEKATIVE ENDOCARDITIS. 



35 



micrococci in the air-cells appeared to be larger than the micrococci in 
the vegetations. My observations, however, on this point have not as 
yet been sufficiently accurate or extensive to enable me to form a satis- 
factory judgment ; and in the mean time I reserve my opinion on the 



-^>7>v.v 







Camera lucida drawing of the cortex of the kidney in ulcerative endocarditis, showing a Malpighian 
tuft stuffed with micrococci. Stained with methyl-violet and eosine, and mounted in zylol balsam. 
X Hartnack, objective 8 ; ocular 3 ; tube out ; and drawing reduced from 4 to 3% inches, a, Mal- 
pighian tuft, the vessels of which are plugged with micrococci ; b, small vessel, passing (?) to the 
Malpighian tuft, plugged with micrococci ; c, renal tubule filled with epithelial cells, the outlines ot 
which are more sharply defined in the drawing than in the preparation ; d, interstitial tissue between 
the tubules, infiltrated with cells which are omitted from the drawing. 

point. Probably this interesting question is more likely to be decided 
by cultivation and inoculation experiments than by simple micro- 
scopical examination. My pathological experience clearly shows 
that during certain seasons (during certain years or certain months) 
acute croupous pneumonia and ulcerative endocarditis are apt to pre- 
vail, but I have not found that when acute croupous pneumonia is 
epidemic, if I may be allowed to use the term, that ulcerative endocar- 



36 



BKAMWELL, ULCERATIVE ENDOCARDITIS. 



ditis also prevails. My experience in this matter is shown in the Table. 
I can, however, confidently say that during the past year, when ulcerative 
endocarditis seemed to be unusually prevalent in Edinburgh, the number 



Fig. 21. 




,Q ■,.,' o" '*>./ 





















Transverse section through the pyramidal portion of the kidney in ulcerative endocarditis, showing 
transversely divided tubules containing micrococci. Stained with methyl-violet and eosine, and 
mounted in zylol balsam. X Hartnack, objective 9; ocular 3 ; tube out; and drawing reduced from 
5% to 4% inches. 

a, "Collecting tube" stuffed with micrococci; b, tube containing numerous micrococci in clusters 
and scattered between the cells ; c, tube containing scattered micrococci and cells ; d, einpty tube ; 
e, bloodvessel ; /, hyaline cast in a renal tubule. 

The epithelium of most of the tubes is proliferating ; the intertubular tissue is infiltrated with round 
cells, the majority of which have, for the sake of clearness, been omitted from the drawing. 

Note. — For the sake of clearness, the individual micrococci are represented larger than the actual 
size. 



BEAMWELL, ULCERATIVE ENDOCARDITIS. 



37 



of so-called septic cases which came under my notice was decidedly 
above the average. 

Table showing the monthly distribution of the cases of acute 
croupous pneumonia and ulcerative endocarditis, which were 
examined post-mortem in the edinburgh royal infirmary during 
the years 1882-83, 1883-84, and 1884-85. 





1882 


-83. 


i 

1883-84. 


1884-85. 


Month. 




Ulcerative 




Ulcerative 




Ulcerative 




Pneumonia. 


endocarditis. 


Pneumonia. 


endocarditis, j 


Pneumonia. 


endocarditis. 


November, 


2 


1 


2 





o 


2 


December, 


4 





1 


1 


2 





January, 


3 





1 


2 





February, 


5 





2 





1 


March, 


4 


1 


2 


2 





April, 


4 





4 








May, 


4 





1 


1 


3 


June, 


3 





3 








July, 


2 





1 1 


5 





August, 








1 1 


o 





September, 


2 








o 





October, 





1 


2 


4 


2 


Total, 


33 


3 


20 3 


•16 


8 



The detection of micrococci in the inflamed cerebral meninges, and in 
the vessels and substance of the cerebral cortex, and the presence of 
disseminated patches of cerebritis and acute cerebral softening, are very 
interesting ; and afford a satisfactory explanation of the nervous symp- 
toms which are so prominent in some cases of the disease. 

The following is the brief record of a very striking and interesting 
case, in which the symptoms were of the type which Osier has termed 
" cerebral." I am indebted for the clinical record of this case to my 
friend, Dr. Berry Hart : 

Case. Endocarditis of the Cerebral Type — A. B., aged thirty-one, was 
seen by Professor Simpson and Dr. Berry Hart for three days only 
before his death. A week previously Professor Simpson happened to 
meet the patient by chance, and seeing that he looked ill, advised him 
to go to bed. Instead of taking Professor Simpson's advice, he went to 
the country, and only returned to town because no improvement took 
place. His friends stated, that for some weeks previously he had been 
greatly out of sorts, complaining of feebleness, suffering from shivering 
and loss of memory, and that, on one occasion, he had fainted. 

He was first seen by Professor Simpson and Dr. Berry Hart on the 
evening of November 1 8, 1884. The temperature was then 103.4° F. ; 



1 It is interesting to note that during the month of November, 1884, two fatal cases of ulcerative endo- 
carditis occurred in the Edinburgh Royal Infirmary. 



38 



BEAMWELL, ULCERATIVE ENDOCARDITIS, 



but with the exception of a well-marked presystolic mitral murmur, 
there were no physical signs of localized disease. 

On the morning of the 9th the temperature was 99.8°, and he was 
troubled with a short cough. Examination of the chest failed to reveal 
any other physical signs than the presystolic murmur previously 
described. 

On November 10th he seemed better, and the temperature, both morn- 
ing and evening, was normal. 

At 4 a.m. on the 11th, and again at 8.30 a.m., he was seized with a 
rigor, the temperature rising to 10-4° F. 

At 12.45 p.m., violent delirium set in, with tetanic spasms (opisthot- 
onus), and localized convulsive movements of both arms and of the mus- 
cles of expression. The temperature rose to 108° F., and death took 
place at 5.30 p. m. 

Fig. 22. 



NOVEMBER 


8 


9 


10 


1 1 




TIMEOF DAY 


M E 


M E 


M E 


M E 


M E 


TEMPERATURE 




















/ 












/ 




















? 










\ 












\ 


/ 










\ 


/ 










\ 


1/ 












I 








98 






LI 







Temperature chart imthe case of A. B., ulcerative endocarditis of the cerebral type. 

Post-mortem Examination. Through the kindness of Dr. Berry Hart, 
I was able to make a post-mortem examination on November 13th. The 
body was well nourished and muscular. The mitral valve presented a 
well-marked, funnel-shaped contraction admitting with difficulty the 
forefinger. The auricular surface of the valve was eroded, the margins 
of the ulcer being covered with a thin layer of recent vegetations ; the 
wall of the left auricle was hypertrophied, but the cavity was in no way 
dilated ; the heart was in other respects normal. 1 



1 This case was a remarkable example of "latent" mitral stenosis in which compensation was unusually 
perfect. It was known that the patient had had a cardiac murmur in childhood ; but he subsequently 
manifested no symptoms of the heart disease ; he presented all the appearances of good health : was 
active, muscular, and had been a good "oar." Shortness of breath, cyanosis, dropsy, and other 
symptoms which are apt to occur in advanced mitral cases, were completely absent. 



ULCERATIVE ENDOCARDITIS. 39 

The spleen was soft and pulpy and greatly enlarged ; its exact weight 
was not ascertained, but it must have been more than one pound. The 
membranes of the brain presented here and there evidences of commencing 
meningitis, the other organs were normal. 

Microscopical Examination. The nerve cells of the cerebral cortex 
were found to be markedly fatty, but no appearances of cerebritis (such 
as were present in the case of Robert Hardie, previously described) 
were found ; there was well-marked commencing meningitis ; micrococci 
were detected in the inflamed membranes, but not in the vessels or sub- 
stance of the cortex. (Whether the fatty degeneration of the nerve cells 
of the brain was of recent origin ; whether it was due to defective blood 
supply the result of the acute cardiac lesion which had evidently been 
slowly progressing for some weeks previous to the onset of meningitis ; 
and whether this fatty degeneration of the nerve cells was the only cause 
of the loss of memory, which was most marked, it is, of course, impossible 
to say. B. B. ) 

Remarks by Dr. Berry Hart. This case was exceedingly puzzling, 
and with the single physical sign of a presystolic murmur, the anom- 
alous crisis on November 10th, as well as the absence of all evi- 
dences of emboli, it was exceedingly difficult to come to any definite 
conclusion. The patient seemed so well on November 10th that we felt 
that our previously expressed opinion of ulcerative endocarditis was 
almost unwarranted. We did not attach sufficient importance to the 
enlargement of the spleen. It is possible that a microscopical examina- 
tion of the blood might have been helpful. The treatment adopted 
consisted of the administration of antipyretics, and, at the last, of the 
free application of iced cloths to the surface of the body. 

While I am referring to the clinical history of ulcerative endocar- 
ditis, it may not be out of place to record briefly three cases of the 
" cardiac type," under which term I include not only those cases in 
which patients the subject of chronic valve disease are attacked with 
febrile symptoms and evidences of a recent endocarditis engrafted uj)on 
the old process, but all cases in which the cardiac symptoms are striking 
and prominent. 

Case. Ulcerative Endocarditis of Cardiac Type. — James Naggs, set. 
thirty-nine, a street porter, was admitted to the Tynemouth Union 
Workhouse, under my care, on October 15, 1873, complaining of short- 
ness of breath, cough, and great debility. 

Previous History. The patient stated that he had always enjoyed 
good health, never having been in bed through sickness for a single day 
until a week ago, when he got wet through, and allowed his wet clothes 
to dry on him. The next day he was " all of a tremble," felt cold, was 
sore, and pained all over his body, as if he had been beaten with sticks, 
began to cough, and had a stitch in the side. He applied to the dis- 
pensary and got some medicine which did him no good ; in two days he 
was so weak that he could not stand, and consequently applied for 
admission to the workhouse hospital. Has never had rheumatism, nor 
rheumatic fever. Has been a tolerably hard drinker. 

State on Admission. Is so weak that he can neither walk nor stand; 
has a frequent, short, dry cough ; complains of pain in the left knee, 
which is swollen ; has had some sweating ; is extremely short of breath, 



40 BEAMWELL, ULCERATIVE ENDOCARDITIS. 

Fig. 23. 







r - ■■' " ' t > 



V'-.>: 



Aortic valve in the case of ulcerative endocarditis (James Naggs) detailed in the text. 

The aortic cusps are thickly coated with vegetations ; two of the segments are ulcerated through, 
pieces of whalebone being placed in the apertures. The letter a points to a small depression (a com- 
mencing aneurism) surrounded by minute vegetations at the base of the aorta, and has evidently been 
produced by the vegetation b, which at every systole would be forcibly washed against the aortic wall 
at this spot. 



BKAMWELL, ULCEKATIVE ENDOCARDITIS. 41 

and very pale, the conjunctivae and lips being almost bloodless ; the feet 
and legs are oedematous. 

Physical Examination. There is marked, visible, jerking pulsation 
in the carotids ; the visible impulse of the heart is larger than normal ; 
the apex is situated in the fifth interspace ; a double bellows murmur, 
the systolic portion being most distinct, is audible at the base of the 
heart. The temperature is 101.3° F. There are no signs of pulmonary 
disease or other complications. 

Progress of the Case. Under rest, nutritious diet, alcoholic stimu- 
lants freely administered, digitalis, and quinine, there was considerable 
improvement; the temperature became normal; the rheumatic swelling 
of the knees and the oedema of the feet and legs disappeared ; and the 
patient was able to sit up for the greater part of the day. Toward the 
middle of November the shortness of breath and debility, which from 
the first had been such prominent symptoms, increased, and necessitated 
his lying in bed; the pallor was now more marked even than on his 
admission. 

The heart was now distinctly enlarged, the apex beat being placed in 
the sixth interspace, and the area of cardiac dulness increased. The 
double aortic murmur, though still audible, was much less loud ; the 
radial pulse was 104, very weak, at times almost imperceptible. The 
skin was cool, the rectal temperature was 101.5° P.; sweating at night 
was a troublesome symptom. 

November 29. The patient had a very bad night, the shortness of 
breath being very great ; fine crepitations are to-day audible over both 
lungs ; the radial pulse is 98 ; temperature normal. 

He died suddenly, apparently from syncope, at 6 p. m. 

Post-mortem Examination. 30th. Body very thin ; an excess of fluid 
in the pericardium and in each pleura ; no subcutaneous dropsy ; both 
legs oedematous ; very marked disease of the aortic valve (see Fig. 
23); the heart moderately enlarged, the left ventricle being dilated and 
hypertrophied; the liver slightly cirrhotic and markedly nutmeg, kid- 
neys healthy ; spleen large and congested. 

Case. Ulcerative Endocarditis of Cardiac Type. — A. B., aged twenty- 
one, was seen by me in consultation with my friend, Dr. Groom, on 
January 17, 1885, suffering from rheumatic fever and endocarditis. 

She had consulted Dr. Croom for anaemia a fortnight previously ; 
and two days after her visit had been seized with rheumatic fever. The 
attack was a severe one, and a mitral systolic murmur and great shortness 
of breath developed at an early stage of the case. 

Under salicylate of soda the joint affection rapidly subsided, and at 
the time of my visit had almost entirely gone ; the temperature, however, 
still kept up, being 102.2° F. ; the breathing was very short and fre- 
quent, and fine crepitant and sibilant rales were audible all over the 
chest ; the heart, more especially the right side, seemed considerably 
enlarged, and a systolic murmur, which was loudest at the left apex, 
was conducted back to the spine ; a faint tricuspid systolic murmur was 
also audible ; there was no pericardial friction. 

Under quinine, alcoholic stimulants, ipecacuanha, and digitalis, there 
was some slight, but only temporary improvement. The difficulty of 
breathing became more marked ; the area of cardiac dulness — apparently 
the result of acute dilatation, and not of pericardial effusion — became 
greater. 



42 BRAMWELL, ULCERATIVE ENDOCARDITIS. 

On January 28th she had a rigor. On the 29th she became hysterical, 
laughing and crying alternately, and being eccentric, both in her manner 
and talk, it was obvious that some cerebral complication was developing. 
There was well-marked inflammation of the right parotid gland. 

On the 80th symptoms of cerebral meningitis were distinct, and death 
took place. 

There was no post-mortem examination. 

Remarks. The rapid development of very free mitral regurgitation ; 
the marked pulmonary engorgement ; the rigors ; and the occurrence of 
cerebral meningitis and of parotitis, leave little doubt that in this case the 
endocarditis was of the ulcerative type. The occurrence of ulcerative 
endocarditis in the course of ordinary rheumatic fever, and where the 
heart was previously healthy, is, according to Osier, rare ; it is well, 
however, to remember that it does occasionally occur, and in any case 
of acute rheumatism in which very free mitral regurgitation, or still 
more when very free aortic regurgitation is quickly established, the 
heart having been previously healthy, the presence of the ulcerative 
forms of endocarditis should, I think, be strongly suspected. 

Case. Ulcerative Endocarditis of Cardiac Type. — Robert Reid, 
set. ten, was admitted to the Edinburgh Royal Infirmary under the care 
of Dr. Miller (to whom I am indebted for the clinical record of the 
case) on April 13, 1885, suffering from a swelling of the left forearm. 

Previous History. The swelling was first noticed about a fortnight 
ago; it arose spontaneously without any injury or other obvious cause; 
for some time before admission the patient had not looked or felt well ; 
immediately in front of the door of the cottage in which he lived, there 
is said to be an untrapped drain. 

History after Admission. The patient was markedly pale and anaemic ; 
the evening temperature on April loth was 101.5° F. 

loth. Dr. Miller made a longitudinal incision over the swelling and 
removed a large blood-clot, which weighed about 8 ounces ; a bleeding 
opening was found in what appeared to be the ulnar artery ; the vessel 
was ligatured above and below, and the wound dressed antiseptically. 

On the evening of April 15th, the temperature was 100.8° F., and on 
that of the 16th 102 D F. ; five grains of quinine were prescribed. 

The morning temperature continued to be about normal and the even- 
ing temperature varied from 101° to 102° F., until April 26th, when it 
reached 103° F. The wound was progressing most favorably. 

22d. Dr. Wylie examined the patient, and found a mitral systolic and 
an aortic diastolic murmur; he diagnosed the case as one of ulcerative 
endocarditis. 

The wound continued after this date to heal satisfactorily, but the 
ansemia, shortness of breath, and extreme debility gradually increased ; 
the temperature continued to fall in the morning and to rise at night ; 
on the evening of May 3d it reached 104° F. 

May 21. Dr. Miller very kindly afforded Mr. Hare and myself an 
opportunity of seeing the patient and of examining the blood. The 
patient at the time of our visit was extremely short of breath ; exceed- 



BEAMWELL, ULCERATIVE ENDOCARDITIS. 43 

ingly pale, and drowsy from cerebral anaemia. The arterial system was 
very imperfectly filled with blood, pulsation in the carotids was very 
visible, jerking and collapsing; there was some swelling of the feet. The 
heart was considerably enlarged; a soft systolic murmur was present in 
the mitral area, and a very faint and short diastolic murmur could just 
be heard at the base of the heart. The area of splenic dulness appeared 
to be increased; there seemed to be no other complications. 

The result of the examination of the blood is detailed in Mr. Hare's 
report. (See page 48.) 

22d. The patient died at 3.15 A. m. 

The post-mortem examination was made nine hours after death. 
Small old adhesions at apex ; aortic valve highly incompetent, covered 
with vegetations ; intercoronary segment ulcerated through, vegetations 
soft and luxuriant, cone diameter 7 ; mitral valve, small vegetation in 
each segment, cone diameter 1.2 ; tricuspid valve healthy, cone diam- 
eter 0.95; pulmonary valves normal; weight of heart 11* ounces; 
ventricles dilated and hypertrophied. Spleen firm. Malpighian bodies 
very prominent ; color dark jxirple ; one small yellow infarct ; kidneys 
normal to naked eye. Lungs : straw-colored fluid in pleura ; some adhe- 
sions between lobes ; on section, very rose colored, oedematous, and con- 
gested at base ; on the posterior surface of the lower lobe an area, one 
inch in diameter, showing small yellow nodules in interlobular septa. 
Brain normal, excepting some excess of subarachnoid fluid ; some micro- 
cocci in cardiac vegetations (Mr. Hare's report) ; none detected in spleen, 
or in clots, after hardening, contained in aneurism of the radial artery 
which had been ligatured. 



Cultivation and Inoculation Experiments. 

Being firmly of opinion that the etiology of ulcerative endocarditis 
and the relationship of the disease to other infective conditions are more 
likely to be determined by experimental means than by any other 
method — an opinion which Professsor Osier has since expressed in his 
Gulstonian Lectures — I requested my friend Mr. Hare to have the kind- 
ness to undertake this part of the investigation. Mr. Hare responded to 
my request with alacrity, and has devoted a large amount of time and 
labor to the matter. Although the results which he has obtained are as 
yet, for the most part, negative, they are undoubtedly of great value 
and interest. 

It may not be out of place to quote Osier's summary of the results of 
previous experiments. " In the way of experimental investigation of 
the properties of the micrococci," he says, "not much has been done of 
a satisfactory nature. Heiberg placed bits of vegetations from a puer- 
peral case beneath the skin and in the peritoneal cavity of a rabbit, 
without effect. Eberth, Birch, and Hirschfeld have produced panoph- 
thalmos in the rabbit by inoculating the cornea; and I was able to pro- 
duce well-marked mycotic keratitis in the same animals with fresh 
material from the valves in two cases. H. Young, of Manchester, 



44 BRAMWELL, ULCERATIVE ENDOCARDITIS. 

inoculated rabbits with pus from an abscess in ulcerative endocarditis, 
and was able to detect micrococci in the blood. 

"No conclusive culture experiments have yet been made. Grancher 
has cultivated a microbe from the blood, taken during life with all 
necessary precautions, but apparently not in series, and no inoculations 
of animals were made. Cornil has made cultures in gelatine, but appa- 
rently no special results have been obtained." 

Mr. Hare informs me that the yellow micrococcus which he obtained 
in his first series of experiments resembles very closely, or is identical 
with the micrococcus of osteomyelitis. This is a point of great interest, 
for " in acute necrosis of bone or acute osteomyelitis," Osier says, 1 " a 
secondary endocarditis may develop, and in some instances the clinical 
features may strongly resemble malignant endocarditis." 2 

In conclusion, I must take this opportunity of thanking Mr. Hare, 
not only for undertaking the investigation, but for the opportunities he 
afforded me of watching the whole inquiry. My thanks are also due 
to Prof. Chiene for allowing the investigation to be conducted in his 
laboratory, and for the great interest which he has taken in the research, 
and to Professor Greenfield and Dr. Woodhead for the facilities which 
they afforded for carrying on the work. 

Keport. 

The following experiments and observations, made with morbid ma- 
terial from certain of the above cases, were carried out by Mr. A. W. 
Hare, Assistant to Professor of Surgery, at the Bacteriological Labora- 
tory of the Surgical Department in the University of Edinburgh, 
through the courtesy of Prof. Chiene. 

First Series (November, 1884). 

These observations were made with material from a case of ulcerative 
endocarditis (case of Robert Hardie), in which there was a widespread 
distribution of miliary abscesses in the liver, spleen, and other solid 
viscera. At the post-mortem examination, portions of these organs were 
transferred to clean glass bottles, and at once sent to the University 
for examination. 

Microscopical Appearances. — The contents of the miliary ab- 
scesses were first examined microscopically. The pus was spread in 
thin films upon cover-glasses, and fixed by Baumgarten's method. The 
pus was then stained by Gram's double stain (gentian-violet and eosine). 
Under a power of 700 diameters (Zeiss y 1 ^ inch homog. immers.) it was 
observed that the contents of the abscesses consisted of pus cells and 

i Loc. cit, p. 507. 2 Loc. cit., p. 459. 



BRAMWELL, ULCERATIVE ENDOCARDITIS. 45 

granular debris, together with considerable quantities of a small-sized 
spherical micrococcus. These organisms appear chiefly as rounded 
clusters with from 6 to 20 cocci in each ; l a few tetrads are also present, 
and some diplococci, whilst at intervals in the specimens examined 
monococci are seen. In whichever of these arrangements the organism 
is observed, the individual unit is uniform in its size, and is of very 
minute dimensions, measuring very little more than 1 fj, in diameter. 
It takes on any of the aniline dyes, whether acid or alkaline, very 
easily, and is beautifully demonstrated by Gram's stain. 

Cultivations in Artificial Media. — These were undertaken in 
the hope of obtaining a pure cultivation of the micrococcus found in 
the miliary abscesses, with a view to testing further the characters of 
that organism. For this purpose sterile tubes of Koch's peptonized jelly, 
and sterile potatoes in glass bell-jars were employed as nutrient soil. A 
portion of the fresh kidney was divided by a sterile (superheated) knife, 
in a still atmosphere, the table and the operator's hands being purified 
with corrosive sublimate solution (one per cent.). Several of the abscesses 
were thus opened, and a small particle of pus was abstracted from the 
centre of each on the tips of a series of sterilized platinum wires. With 
the seed material thus separated, a series of tubes of jelly and of sterile 
potatoes were inoculated. 

Result in Jelly. — One tube reacted, three did not. The tube 
which reacted showed the following appearances. A gray, finely granu- 
lar prolongation was seen running down in the gelatine in the line of 
inoculation. On the seventh day liquefaction set in, and gradually a 
funnel-shaped liquefied part formed in the centre of the gelatine. At 
the tenth day the whole circumference of the top of the gelatine was 
involved in this process, and liquefaction in four weeks had extended to 
the bottom of the tube, where a fine, amorphous, yellow-gray precipi- 
tate was deposited. This yellow-gray deposit w r as examined micro- 
scopically, and found to consist mainly of micrococci of small size ; 
many of these were bereft of life, as was evidenced by the faint staining 
reaction resulting on the addition of methyl-violet, and large quan- 

1 This prevailing arrangement of the cocci in clusters of spherical shape is also noticed in pus from 
osteomyelitic and periostitic cases. It is not due to mechanical conditions as is the rounded shape of 
micrococcus emboli in the circulating blood, for there is no active movement in the contents of an 
abscess. It must, therefore, be looked upon as a vital peculiarity of these species of micrococci, to 
which the name of sphserococci might well be applied to differentiate them from other morphological 
types. The proximate cause of this special feature is to be looked for in the mode of multiplication 
which is found to occur in the organisms. All micrococci multiply by fission ; the cleavage which 
occurs is either constantly in one plane, producing diplococci or streptococci (chains), alternately in 
two planes at right angles with one another (tetracocci, sarcinse), consecutively in each of three planes 
at an angle of one hundred and twenty degrees with each other, which produces the sphserococcus 
now noticed, or in an indefinite series of planes in which no regular sequence can be traced, giving rise 
to the type of staphylococcus. This law also holds true, to some extent, of the forms of growth dis- 
played by the same organisms in artificial media, and gives a possible future basis on which a morpho- 
logical classification of micrococci may be constructed. 



46 BEAMWELL, ULCERATIVE ENDOCARDITIS. 

titles of amorphous debris, amongst which a number of short, straight 
bacilli were seen. 

Secondary and tertiary cultivations followed the same course, as did 
also cultivations in gelatine from the growth which had occurred on the 
inoculated potatoes. (These cultures were used in Experiments 1 and 2.) 

Result of Inoculation of Potatoes. — On potatoes the organism 
grew as a yellow-gray, thick, and moist pelKcle. In some parts it was 
more purely yellow, in others a duller drab color. A pure cultivation 
of the drab variety of organism was procured and used for the inocula- 
tion subsequently described. Two attempts to get pure cultivation of 
the yellow element failed, and it was not used for inoculation experiments 
till a subsequent date, when, after repeated failures, a pure growth of 
the yellow organism was obtained. 

The gray colored growth was found to consist of short, straight bacilli 
in immense clusters. (Used in Experiments 3 and 4.) The yellow growth, 
when first obtained, consisted solely of micrococci of small size, in irregu- 
lar clusters. This cultivation was employed subsequently in making 
inoculation experiments ; but at the time it was used it had become con- 
taminated and was not pure, having assumed a buff color and lost its 
bright yellow tint. (Used in Experiment 5.) 

Inoculation Experiments. — These were performed in the Patho- 
logical Department of the University, through the courtesy of Professor 
Greenfield and Dr. "Woodhead. 

A. With cultures in nutrient jelly. 

Experiment 1. — A tube of jelly in which liquefaction was well 
advanced, and in which there was a yellow amorphous deposit, was 
employed in this experiment. The liquefied portion and the deposit 
were thoroughly mixed by agitating the contents of the tube — and fifteen 
minims of the turbid fluid thus obtained were slowly injected into the 
largest efferent vein of the left ear of a rabbit. (Plain white.) 

Control Experiment 1 a. — A tube of sterile jelly had its contents 
liquefied by heat, and fifteen minims of its contents were injected into 
a vein of the ear of another rabbit. (Black back.) 

Experiment 2. — A small pocket was made in the subcutaneous tissue 
of a rabbit's ear (black and white " spot ") and a drop of turbid fluid 
from the same cultivation introduced. 

Result. — In no case was there any reaction, local or general. The 
animals remained in good health, and after some weeks one of them 
(black back) was used for another experiment (see Experiment 5). The 
other two were not made use of again in this series of experiments. 

Deductions from Result. — Experiment 1 was intended to ascertain 
if organisms derived from a case of ulcerative endocarditis were capable 
of giving rise to the disease when they were introduced into the blood- 
stream of a lower animal. 

Experiment la was intended as a check upon this by ascertaining 



BEAMWELL, ULCERATIVE ENDOCARDITIS. 47 

whether the constituents of the nutrient media themselves were free 
from pathogenic properties. 

Experiment 2 was devised to obviate the misleading result that might 
appear in consequence of the immediate devitalization by the blood- 
stream of foreign elements introduced into it, 1 as is found to be the case 
with pure cultivations of bacterium termo; where the organism is de- 
stroyed before it can commence any pathogenetic action. A local focus 
was therefore established apart from the blood stream, where there was 
a possibility of the elaboration of products, by absorption of which a 
secondary infection (autoinoculation, Verneuil) might occur. This was 
based on the frequency with which ulcerative endocarditis is seen to 
follow surgical affections in the human subject, the general disease being 
in these cases secondary to a localized lesion. (This principle was still 
further developed in Experiment 4.) The negative nature of the results 
obtained pointed to a series of alternative conclusions, viz. : 

1. The organism injected is not a mater les morbi. 

2. The organism cultivated, primarily infective, has become inert : 

a. From extraneous contamination (presence of bacillus in tubes 
along with micrococcus) ; 

b. From intrinsic alteration due to artificial surroundings. 

3. The condition of the animal was not such as to admit of the 
organism exerting its pathogenetic activity, from the animal possessing : 

a. Constitutional immunity ; 

b. Vital activity sufficient to throw off the irritant in these particular 
cases. 

With a view to pressing the matter to a further conclusion, the follow- 
ing experiments were planned and carried out. 
B. With cultivations on potatoes. 

Experiment 3. — The gray pellicle cultivated on potato was mixed 
with liquefied sterile jelly, and an emulsion made, and ten minims of the 
emulsion were injected into the veins of a (gray) rabbit's ear. 

Experiment 4. — Fifteen minims of the same emulsion were injected 
into the right auricular vein of another rabbit (brown and white). A 
sterile needle was introduced into the hind leg of this rabbit, and the 
periosteum of the tibia detached on the anterior surface for one-third 
the length of that bone. 

Results. — The rabbit used in the latter experiment remained in per- 
fectly good health. 

The rabbit used in Experiment 3 developed morbid symptoms in 
twenty-four hours. It had no appetite, was lazy in its movements, and 
its eyes were dull and bleared. On the second and third days it grew 
worse, and on the fourth day seemed moribund ; it lay on its side, it 
was not able to move, and its breathing was labored. On the fifth day 
it seemed to have passed some crisis and was less affected ; and on the 
sixth day it was much better and recommenced to eat, but did so sparingly. 

1 Cf. Hiller's experiments with septic organisms. "Die Lehre von der Faiilniss," Berlin, 1879. 



48 BRAMWELL, ULCERATIVE ENDOCARDITIS. 

On that day it was killed by dividing the spinal marrow high up, and 
the state of the organs examined. All the organs were found to be 
healthy, except the lungs, which showed patches of superficial hemor- 
rhage; kidneys normal ; spleen small and shrunken. In the heart, some 
small pink clots were adherent to the tricuspid valve, resembling vege- 
tations, but containing no micrococci. Blood examined, but no micro- 
organisms were detected. 

Deductions from Results. — These two experiments were performed 
to test the pathogenetic activity of the potato cultures ; in the latter, a 
local focus for the action of the organism was provided by the injury to 
the periosteum, following the plan devised by Becker in his experiments 
upon infectious osteomyelitis (Deutsche med. Wochenschr., Bd. 9, 1883). 
The general conclusions are identical with those derived from Experi- 
ments 1 and 2. 

The rabbit used in Experiment 3 probably suffered from a temporary 
attack akin to septicaemia, which it threw off on the fifth day. The 
shrunken spleen points to this conclusion. 

These inoculations having been made with the gray film cultivated 
upon potato, and that film having been subsequently found to consist of 
bacilli ; the yellow film, which had been in the mean time procured pure 
and found to consist of micrococci, was used as follows: 

Experiment 5. — A portion of the cultivation made from the yellow 
colored part of previous cultivations, which had recently assumed a gray- 
ash color owing to the presence of a contaminating bacillus, was scraped 
off with a sterile knife, mixed with boiled distilled water, and fifteen 
minims of this emulsion inoculated into the vein of a rabbit's ear 
(black-backed white rabbit). 

Result. — No reaction ; animal remained perfectly well. 

Conclusions. — The results of this series of experiments are entirely 
negative. The causes of which these results are the outcome have been 
already referred to (deductions from Experiments 1 and 2). The two 
chief features of doubt left are, as to whether these experiments were 
performed with the supposed special organism, and upon a species of 
animal susceptible to the disease. One practical result accrued, however: 
the decision was come to that in future cases, should they occur, it would 
be the experimenter's duty to take the organism direct from the local 
lesion, and introduce it into the circulation or tissues of several species 
of the lower animals, till one be found liable to an attack of the disease. 
The difficulties which stand in the way, in this respect, are more of a 
legal than of an experimental nature. 

Second Seines (May, 1885). 

In this series of experiments, morbid material was made use of from 
two sources (cases of R. Reid and J. Sweeney). In the former of these 
cases, the disease was diagnosed during the lifetime of the patient, and 



BRAMWELL, ULCEEATIVE ENDOCARDITIS. 49 

the following observations were made by the kind permission of Dr. 
A. G. Miller. 

Microscopical Examination of Blood. — Cover-glasses were pre- 
pared, on each of which was a thin film of the patient's blood, which 
was stained by Gram's method. Out of six specimens examined under 
the microscope (X 700), two were found to contain microorganisms in 
very small numbers. Several fields of the microscope had to be carefully 
searched before a single specimen of the organism could be detected. 
The organisms demonstrated were all micrococci, in one or two cases in 
the dumbbell-form (diplococci), but most of those seen were isolated units. 
They were, as a rule, free in the liquor sanguinis ; one leucocyte was 
found which had ingested a diplococcus. The individual cocci were of 
small size, measuring barely one // in diameter. 

Cultivation Experiments. — It was impossible to take blood in suf- 
ficient quantity from the patient to make direct inoculation with it into 
animals a promising proceeding. It was accordingly decided to attempt 
to establish artificial cultivations, by inoculating artificial nutrient media 
with small doses of the patient's blood. The patient's finger was pricked 
with a sterile needle, after a thorough preliminary cleansing of the part 
with soap and water, corrosive sublimate solution (1 : 1000), and absolute 
alcohol, applied in that sequence. From the centre of the drop of blood 
which exuded, a trace was removed on the tips of a series of sterilized 
platinum wires, by which the following media were inoculated : Koch's 
jelly, agar-agar solution, inspissated serum (hydrocele fluid solidified), 
and sterile potatoes. The three last-named media were incubated for 
eight days at blood heat for four hours each day. No reaction occurred 
in any of these media : they remained perfectly sterile. 

Inoculation Experiments. — The autopsy of the case just described 
was held eight hours after death. A sterile Pravaz syringe was filled 
with fluid blood from the innominate vein, before that vein was in any 
other way interfered with. A portion of the vegetation found on the 
cardiac valve was transferred, with aseptic precautions, to a sterile flask ; 
and these materials were taken to the University for experimental pur- 
poses. On the same day another case (J. Sweeny) of ulcerative endo- 
carditis was examined in the post-mortem theatre; a portion of the 
vegetation on the aortic valves in this case was also removed and 
employed along with the previously mentioned material in the experi- 
ments of this series as follows : 

Experiment 1. — Needle of syringe introduced into a large vein of 
rabbit's ear; and 12 minims of the blood injected slowly into circulation; 
a single drop of blood was introduced similarly into the subcutaneous 
tissue of the neck of the same animal (large white rabbit). 

Experiment 2. — Large vein of black rabbit's ear laid bare by small 
valve-like incision through the skin; vein then opened by carefully 

NO. CLXXXIII. — JULY, 1886. 4 



50 BRAMWELL, ULCERATIVE ENDOCARDITIS. 

planned longitudinal incision, into which portions of vegetation from the 
valve of the heart were at once inserted. More of the same material was 
introduced under the skin into the wound. The wound was then closed; 
very slight hemorrhage occurred beneath the skin, where it had been 
detached, and formed with the material introduced into the wound a 
hard clot. 

Experiment 3. — Small pocket made in skin of brown rabbit's ear, 
and a portion of vegetation from aortic valve of heart introduced below 
the skin. 

Result. — The three animals remained entirely unaffected, and con- 
tinued perfectly well for several weeks, during which period they were 
kept under observation. In the animal employed in Experiment 2 the 
clot formed at the time of the experiment was subsequently absorbed, 
and the vein operated on remained patent — a slight scar at the site of 
the wound was the only evidence of its having been made. 

Conclusions. — The experiments of this series were intended to sup- 
plement those of Series 1. In this case an organism present in the dis- 
ease was with certainty, in all three experiments, introduced under 
varied conditions into an animal. The organisms had been demonstrated 
during life in the blood in the one case, and post mortem in the vegetation 
in both cases. The conditions w T ere varied in each of the three experi- 
ments. In Experiment 1 a considerable amount (twelve minims) of 
blood containing an organism was introduced into the circulation of the 
animal, and lest the foreign particles should be at once devitalized by 
the healthy blood of the animal, a local focus for morbid action was 
provided by introducing some of the morbid blood into the subcutaneous 
tissues of the neck. In Experiment 2 the organisms demonstrated in 
the vegetation were given access both to the blood stream and to the 
surrounding tissues, the latter in this case depressed by the operation 
performed. In Experiment 3 a condition was established similar to 
that induced in the secondary part of the preceding experiment. 

In all three the results are negative, not, however, definitely so as re- 
gards the pathogenic power of the organism employed, nor as regards 
the susceptibility of the animal acted upon. The legal difficulty already 
referred to here presented itself, in the small number of species at com- 
mand for experimental purposes. One further measure commended 
itself for trial even in these unsatisfactory conditions, viz., the employ- 
ment of very large doses of the morbid material. This was carried out 
in the last series of experiments. 

Third Series (June, 1885). 

Inoculation experiments only were here performed, the morbid matter 
introduced being obtained from a well-marked case of ulcerative endo- 
carditis (A. Blythe), in which the organisms were abundantly present 
in the vegetation. In this case the post-mortem examination was made 
twenty-four hours after death, the body showed no evidence of putre- 



BEAMWELL, ULCERATIVE ENDOCARDITIS. 51 

faction. A mass of the vegetation was removed with aseptic precau- 
tions, mixed with 3J of distilled water, and rubbed down into an 
emulsion. A rabbit (brown) was placed under the influence of ether, 
and its left jugular vein laid bare by an incision two inches long. The 
needle of a hypodermatic syringe was pushed through the wall of the 
vein into its lumen, and twenty minims of the emulsion of vegetation in- 
jected into the blood stream. The needle was then withdrawn and some 
of the emulsion deposited in the wound, along with flaky portions of the 
vegetation ; the wound was closed by drawing the parts together, but 
no sutures were employed. The day after the operation the wound was 
covered by a dry scab. The animal showed then and subsequently no 
symptom of ill health. 

General Conclusions. — No definite result has been attained by these 
three series of experiments. Some opinions may be based upon them, of 
which the most important is, that the " much-experimented-on-rabbit " 
is not susceptible to human ulcerative endocarditis. Had positive re- 
sults accrued to the methods employed in Series 2 and 3, the method of 
Series 1 would have been subsequently introduced, in order that by cul- 
tivation experiments a distinct materies morbi might be separated. The 
method of Series 1, which may be termed the mediate method of investi- 
gation, can only in the mean time give results of special interest to the 
germiculturist, until the immediate method of investigation, by direct 
inoculation of morbid products, has demonstrated some species of animal 
in which the disease may be experimentally produced. 

Note by Mr. Hare. — Since the above described experiments were 
performed, some important experimental work upon the subject has 
been published, to which it will be well to refer shortly. During 
last year, Wyssokovitsch, 1 working in the laboratory of Professor Orth, 
undertook an experimental research with a view to producing ulcer- 
ative endocarditis artificially in the lower animals. He made use of 
rabbits in carrying out these experiments, employing pure cultivations 
of the micrococci obtained from pus in acute inflammatory conditions 
as a materies morbi. A fine probe was introduced into the carotid 
artery and passed down to the commencement of the aorta, so as to 
cause abrasion of the aortic valves. When the valves had been in 
this way prepared for the supervention of morbid processes, a consider- 
able quantity of the infective material was thrown into the blood stream, 
and the animal soon exhibited all the symptoms of ulcerative endocar- 
ditis, and upon post-mortem examination presented the typical appear- 
ances of that disease. By simple injection, without injury of the valves, 
Wyssokovitsch failed to produce the disease. It was found that when 

1 Centralblatt f. d. med. Wissenschaften, 1885, No. 33. 



52 BEAMWELL, ULCERATIVE ENDOCARDITIS. 

produced artificially, the disease was in the first place strictly limited to 
the irritated area, spreading not by extension of superficial ulceration 
but by a destructive process which disintegrated the subjacent tissues. 
Shortly after the publication of these results the question was taken up 
by Professor Ribbert, of Bonn, who has now published the results of 
further experiments. 1 Making use of the staphylococcus aureus 2 in pure 
cultivations, he injected very large quantities of the infective material 
into the blood stream of rabbits, without in any way causing previous 
injury of the cardiac valves. By this means he produces an infective 
myocarditis in all cases ; and in cases where very large doses of the in- 
fective material are employed, endocarditis is present in addition to the 
numerous points of suppurative action found in the muscular structure. 
Vegetations are produced on both sides of the heart, the mitral valve 
being usually more affected than the tricuspid, whilst the aortic and 
pulmonary valves are unaffected. If small doses of the infective 
material be introduced, the animal still dies of a pysemic condition, but 
the disease is not so rapidly fatal as in the ulcerative cases. Where 
ulcerative endocarditis is present, death usually takes place in from 
twenty to twenty-four hours ; where it is not present, the animal may 
not succumb till the fifth day. 

It comes to be a question how far this experimental pysemia really 
coincides with ulcerative endocarditis in the human subject. In their 
most violent forms the two conditions would appear to be very closely 
related — i, e., where miliary abscesses and valvular lesions are both 
present. 

Whether the experimental infection corresponds to the less rapid 
cases of ulcerative endocarditis in the human subject in which pysemic 
conditions are absent, must be determined by future investigation. It 
would appear that there is a close parallelism in certain cases between 
the action of the pus-producing organism when thrown into the circula- 
tion, and that of the special (and, as yet, not fully described) organism 
associated with ulcerative endocarditis ; but this parallelism has not as 
yet been shown to extend over a sufficiently wide series of cases to estab- 
lish their identity. 

i Fortschritte d. Medicin, Jan. 1886. 

2 Rosenbach, microorganisrnen bei den Wund-infections-krankheiten des Menschen, 1884. 



NEPHRITIS. 53 



SCARLATINAL NEPHRITIS, 



By I. E. Atkinson, M.D., 

PROFESSOR OF THERAPEUTICS AND MATERIA MEDICA AND CLINICAL MEDICINE IN 
THE UNIVERSITY OF MARYLAND. 

Scarlet fever derives most of its dangers from disorders that compli- 
cate or succeed it. Of these, the most important are derangements of 
the kidneys. Indeed, a number of recent writers assert that these 
organs are constantly affected in scarlet fever. Eisenschitz declares 
that renal catarrh is just as much a feature of scarlet fever as bronchial 
catarrh is of measles. Frerichs, Reinhardt, Begbie, Newbigging, 
Holder, and others, maintain the same opinion. The three last-men- 
tioned authors found albuminuria in their cases of scarlet fever without 
exception (Gee). Boning, who likewise regards renal derangement as 
constant, found it only to a slight degree in most of his cases, but often, 
also, encountered diffuse croupous nephritis, which, however, only seldom 
passed into chronic parenchymatous nephritis. 2 

Future research may show that simple renal catarrh accompanies all 
cases of scarlatina, but it is certainly not true that renal alterations 
competent to excite albuminuria or to reveal themselves post mortem to 
reasonably careful inspection, are invariably present. Thomas practised 
microscopic examinations in twenty-five of eighty patients, and in twenty 
of these daily. In the prodromal and eruptive stages he found albumin- 
uria only rarely, and then it was transitory and very slight. Signs of a 
decided alteration in the urinary tract were most uncommon — symptoms 
of mild catarrh were more often seen. Only the more severe forms were 
considered by Thomas to depend upon a specific scarlatinal influence. 3 
Pathological anatomy would seem to bear out such conclusions, for 
although Steiner states that evidences of kidney disorder are always 
present in those who die of scarlatina, whether signs of it were present 
during life or not, Friedlander, who examined the bodies of 229 scarlet 
fever cases, after death, found kidney disorder in a little less than one- 
half. Moreover, it must be admitted that fatal cases of scarlatina are 
vastly more apt to present renal disorder than those which recover. 

Renal catarrh, however, is much more frequently an accompaniment 
of scarlatina than is generally supposed. It usually escapes observa- 
tion, as it is only exceptionally revealed by symptoms and can only be 
recognized after microscopic examination of the urine, a procedure too 



1 Eead before the Clinical Society of Maryland. 

2 In a paper read before the Royal Medical and Chirurgical Society, a synopsis of which appeared in 
the Lancet (Nov. 14, 1885), Dr. Stevenson Thomson, after examination of the urine of 180 cases of 
scarlet fever, favored the view that nephritis is a feature of scarlet fever almost as essential as the rash 
or sore throat. 

3 Jahrb. f. Kinderheilk., 1870, i. 



54 ATKINSON, SCARLATINAL NEPHRITIS. 

often neglected, but of the greatest importance as often anticipating 
dangerous processes that may be averted by timely treatment. Thomas, 
in denying that this condition is at all constant, shows that it also occurs 
in measles, croupous pneumonia, intestinal catarrh, etc., and is often but 
an expression of the febrile condition. At the same time, the catarrh 
is relatively so frequent in scarlatina that he cannot avoid the conclusion 
that the specific influence of the disease is often concerned in its produc- 
tion, especially as there is frequently a disproportion between the degree 
of fever and the signs of renal irritation. Careful observation will 
detect in many cases from the very beginning, heaped-up masses of renal 
epithelium, like cylinders, some more or less degenerated or changed 
into detritus. In milder cases the urine will contain long, flattened 
mucous casts with increased quantity of mucus, but no albumen. In 
severe cases the urinary sediment will show more hyaline casts studded 
with epithelium and epithelial debris, and red and Avhite blood-cor- 
puscles. Slight albuminuria will also be present. This catarrh is for 
the most part insignificant, and probably only rarely serves as the 
starting-point for the graver, pronounced, and characteristic forms of 
nephritis scarlatinosa, though, without doubt, many milder forms of 
scarlatinal nephritis and dropsy originate in it. Boning and others have 
observed it pass into croupous parenchymatous nephritis. Thomas con- 
cluded that those cases in which nephritis develops suddenly and not 
from preceding renal catarrh, usually end fatally. 

Inflammation of the kidneys sufficiently pronounced to excite albu- 
minuria varies greatly in the relative frequency of its occurrence. In 
some epidemics it appears in as many as 70 per cent, of cases, while in 
others not more than 5 per cent, may be attacked. Dickinson, in quoting 
Hillier's observation that at the Children's Hospital about half of the 
cases of scarlatina had albuminuria, considered the statement as rather 
below than above the truth. 1 Fleischmann, at St. Joseph's Hospital in 
Vienna, noted 95 cases of Bright's disease in 472 observations. During 
1861, every third child with scarlatina had dropsy; Avhile during 1862, 
it developed in only one in ten. 2 Thomas asserts that renal alterations 
develop in about one-half of all cases of scarlet fever ; while, as has been 
already shown, there are those who assert that they are present in every 
case. On the other hand, Jaccoud declares that for fifteen years he has 
never had a case of scarlatinal nephritis among his scarlet fever patients, 
a result that he attributes to his treatment. 3 Albuminuria may appear 
at any time during the attack of scarlatina from the very first day, 
though its most common occurrence is during the second and third 
weeks. Obviously, dropsy should not be taken as marking the begin- 

1 Albuminuria, page 320. 2 j a hrb. f. Kinderbeilk., 1870, 411. 

3 Gazette des Hopitaux, 58, 1885, 418. 



ATKINSON, SCARLATINAL NEPHRITIS. 55 

ning of nephritis, the signs of which may be present in the urine for 
hours, even days, before this occurs. Fleischmann noted the appear- 
ance of dropsy in his cases, 9 times during the first week, 30 times 
during the second week, 23 times during the third week, 20 times during 
the fourth week, and 5 times after the fourth week. Of 60 cases at the 
Children's Hospital, 42 began between the end of the first and the end 
of the fourth week, while 5 became dropsical during the first week. 

When nephritis occurs during the first week of scarlatina, it often 
escapes attention at the beginning, on account of the blending of its 
symptoms with those of the essential disease and of the neglect of the 
attendant to examine the urine. Dropsy will, of course, attract notice, 
but this does not often occur so early, and may be confounded with the 
oedema due to the exanthem. Rarely, the fatal issue of what was, appa- 
rently, malignant scarlet fever, really may have resulted from a uremic 
poisoning due to a fulminating nephritis. In either case the symptoms 
may have been identical. Fever, vomiting, headache, delirium, amblyopia, 
coma, convulsions, may have been present. The convulsions are often very 
irregular. They may be general, partial or unilateral, tonic or clonic. The 
patient may have several in rapid succession, or may pass into a status 
epilepticus from which only death will release him. In nephritis of this 
character the urine will be completely or partially suppressed. That 
secreted will be of high specific gravity (1.020 to 1.040), dark and smoky 
in appearance, loaded with albumen, and depositing an abundant sedi- 
ment of hyaline, epithelial, granular, and blood-tube-casts, with renal 
epithelium and red and white blood-corpuscles in greater or less 
quantity. 

According to Glax 1 and others, the very diminution, to great extent, 
of the urine, during scarlatina, is ominous, as indicating renal compli- 
cations, and death has been known to follow before albuminuria was 
established. If the kidneys become implicated toward the end of the 
first week, the development of symptoms may delay the course of what 
may otherwise appear to be a normal case of scarlet fever. Microscopi- 
cal research will often betray the onset of the changes in advance of 
chemical analysis; casts of the renal tubules will be observed, along 
with epithelial deposits and detritus, before albuminuria is developed. 
This, however, will shortly appear, and in severe cases the scarlatinous 
symptoms will be interrupted by those of the nephritis. There will be 
no constant relation between the amount of albumen, the tube-casts, and 
the general detritus — one variety of sedimentary matter being at one time 
copious, at another very scanty. At this time vomiting may begin with 
returning headache, the appetite may again fail, pain in the loins may 
become annoying ; the patient may again become depressed and feeble, 

1 Deutsche Archiv f. klin. Med., 33, 1883. 



56 ATKINSON, SCARLATINAL NEPHRITIS. 

and his fever may cease to diminish — may even exceed its original inten- 
sity. At other times no apparent influence will be exerted upon the 
scarlatina, which will run its usual favorable course until the occurrence 
of dropsy and albuminuria reveals the implication of the kidneys. 

When the renal disorder develops after defervescence, during the 
second, third, or fourth week, or later, the same series of symptoms 
may be observed, their severity being generally in direct ratio to the 
earliness of their occurrence. Thomas thinks that cases developing 
after the fourth week may be expected to run a favorable course. It 
has been asserted that the renal disorder may arise after several months; 
but if a patient pass the sixth week in safety, he will almost certainly 
escape. The symptoms, in cases arising during these weeks are not 
always gradually developed, and some of the most disastrous results of 
the disease may be encountered during the second, third, or fourth 
weeks in children apparently convalescing from scarlatina, and often in 
full desquamation, who, after a few hours' indisposition with nausea, 
headache, malaise, confusion of ideas, or stupor, with return of fever, 
rapidly pass into coma or convulsions ending after a short interval in 
death, before dropsy has developed and after partial or complete sup- 
pression of urine. 

It is the rule for scarlatinal nephritis to pursue a mild and favorable 
course. Dropsy is usually the first symptom observed, first appearing 
in the face, and sometimes remaining confined to that locality ; at other 
times becoming speedily general, and giving an appearance of plump- 
ness, but with a waxy translucency of skin. The face, upper and lower 
extremities, body wall, and prepuce may thus become dropsical. The 
serous cavities are very often implicated, and more or less filling of the 
pericardial, pleural, 1 peritoneal, scrotal, and intracranial cavities occurs. 
(Edema of the lungs and of the glottis not very infrequently imperils life. 
Desquamation is often completely arrested upon the supervention of 
dropsy. The temperature, which in the more severe cases may be much 
elevated, is more commonly but little above normal, not exceeding 101° 
or 102° F. The pulse, sometimes accelerated and feeble, will often become 
remarkably slow and intermittent, and so remain throughout the attack. 
The child will grow dull and listless, and exceedingly feeble. Pain in 
the belly and in the back will at times prove very annoying, or, again, 
may be absent. The tongue, having lost the strawberry aspect of the 
stage of eruption, will become pale, flabby, and coated, the appetite will 
fail, and the bowels become sluggish. The urine will rapidly diminish 
in quantity, and may deposit urates copiously, or may present a smoky 
and oily appearance, due to the abundant presence of epithelial cells, 
white and red blood-corpuscles, and tube-casts. The total amount may 

1 The hydrothorax is sometimes unilateral. 



ATKINSON, SCARLATINAL NEPHRITIS. 57 

now be reduced to a few ounces. Blood corpuscles are often very abun- 
dant, and form a thick red layer at the bottom of the test-tube. This 
free admixture of blood may at times amount to very well-marked 
haematuria. Such haematuria is generally post-scarlatinal, and, accord- 
ing to Schiitz, occurs during the third or fourth week most frequently. 
Ordinarily, of itself, it adds but little to the gravity of the case. The 
patient often feels fairly well, and may eat and sleep with comfort. 
While the oedema and pallor may be very great, the temperature, and 
pulse may vary but little from the normal, or may show the changes 
of ordinary scarlatinal nephritis. With the gradual improvement of 
all the symptoms, the haematuria disappears. Heubner 1 has reported 
a case of nephritis after scarlatina in which hemoglobinuria was present. 
The urine became brownish-black ; no blood corpuscles were present. 
Death resulted from asthenia on the fifth day after both albumen and 
haemoglobin had disappeared from the urine. 

The amount of albumen in the urine in scarlatinal nephritis is usually 
very great. The urinary sediment is also abundant, and is largely com- 
posed of tube-casts. Hyaline casts predominate ; though finely and 
coarsely granular, and epithelial casts are numerous ; later, coarse fatty 
granules stud the casts plentifully. The casts are often almost diffluent, 
and differ strikingly from the firm and sharply outlined casts of more 
chronic nephritis. They are sometimes of enormous size, coming from 
the larger tubules. Crystalline deposits are scanty, and are mostly con- 
fined to uric acid and urates. On the other hand, the amorphous urates 
are often very abundant. The extent of the albuminuria present is of 
less importance than the total quantity of urine, rapid and extensive 
diminution of this being most ominous as indicating the accumulation of 
nitrogenous waste in the blood and danger of resulting uraemia. Glax 2 
has been able to draw important conclusions from the amount of urinary 
water in scarlatina. He recognizes three types, after which the urine is 
secreted: 1. The total urine is only lessened so long as the fever con- 
tinues, after which it gradually increases until the normal amount is 
reached, or, for a few days, even exceeded. In such cases the course is 
always favorable, desquamation occurs promptly, and albuminuria is 
absent. 2. Diuresis increases after the beginning of fever, often very 
considerably, then during the following days markedly diminishes, 
and shows notable variations during the attack. In these cases the 
course is protracted, desquamation imperfect, and the heart's action 
weak. Anaemia frequently develops, cutaneous oedema not seldom, 
but the urine remains free from albumen. 3. Micturition, which 
during the fever was much diminished, quickly returns to the normal 
with defervescence, and then suddenly again diminishes, and remains 

1 Deutsches Arch. f. klin. Med., xxiii. 288. 2 Ibid., xxxiii., 1883. 



58 ATKINSON, SCARLATINAL NEPHRITIS. 

scanty until death, or after several days polyuria develops, which slowly 
sinks to normal diuresis. These are the cases in which, after a normal 
course, nephritis and dropsy occur later. A lessening of the propor- 
tion of urine secreted to fluid ingested (2 : 3) not unfrequently fore- 
shadows the approach of ursemic symptoms, even though the urine con- 
tains no albumen. 

Whether, throughout the attack, the temperature remain normal or 
after an initial chill become elevated and all the symptoms of acute, 
nephritis develop, complete recovery may reasonably be expected if the 
patient pass safely through the earlier phases of the disorder. But 
although nephritis and dropsy may be slight, albuminuria lasting only 
a few days and anasarca being limited to mild pufnness about the eyes, 
scarlatinal nephritis does not usually subside entirely in less than a 
month. It may endure as long as three, four, or five months, and, 
rarely, there seems good reason to believe that chronic nephritis in 
young people may have had its beginning in antecedent scarlatinal 
inflammation of the kidneys. Such a result, however, is exceedingly 
uncommon. 

The dropsy is indicative of the degree of renal derangement, except 
in the most acute cases, and sometimes reaches enormous proportions — 
as the urine increases in quantity the albumen proportionally diminishes 
and the dropsy disappears ; the skin, which until now has been dry and 
inactive, becomes softer, more elastic, and resumes its proper functions. 
The appetite improves, the spirits, strength, and mental activity return, 
and good health gradually becomes restored. Just as the microscope 
reveals the earliest evidence of renal derangement, so does it continue 
to expose the results of pathological action after chemical tests fail to 
do so. Tube-casts continue to appear in the urinary sediment, some- 
times for weeks after the cessation of albuminuria, the epithelial, blood, 
coarsely granular, and fatty casts gradually giving place to finely 
granular, hyaline, and mucous ones, which, in their turn, finally disap- 
pear. When the disorder terminates fatally, the symptoms will be 
those of acute nephritis : suppression of urine may be followed by signs 
of cerebral disturbance, headache of violent character, during which 
blindness occurs very often, with or without dilatation of the pupil, 
vomiting and convulsions, partial or general, coma, and sometimes 
paralysis ; or the fatal termination may slowly be reached through con- 
stantly increasing asthenia ; or, what is quite frequent, complications 
may arise which cannot always definitely be ascribed to the nephritis or 
to the scarlatina itself. These are inflammations of the pleurse, the 
pericardium, the endocardium, the peritoneum, the cerebral meninges, 
etc. Pneumonia, acute articular rheumatism, or enteritis, may also 
hasten the fatal issue. 

Cases are occasionally observed in which dropsy follows scarlatina, 



ATKINSON, SCARLATINAL NEPHRITIS. 59 

but without albuminuria. Indeed, a tendency toward non-albuminuric 
dropsy after scarlatina lias been associated with certain epidemics. 
Scarlatinal dropsy without renal affection has been observed by Guer- 
sant, Killiet and Barthez, Noirot, Bouchut, Loschner, Duckworth, and 
others. Quincke 1 tries to explain such cases of non-albuminuric dropsy 
as not depending upon nephritis, but as a consequence of the scarlatinous 
irritation exerting some peculiar influence upon the connective tissue. 
Such cases probably occur in the experience of most busy practitioners. 
One should be cautious, however, in deciding against a nephritic origin 
of these dropsies, except where they can be definitely attributed to anaemia 
and debility. Hennoch 2 has asserted that cases of nephritis occur in 
which albuminuria is absent up to the time of death. He reports a 
case in which anasarca was present for three weeks after scarlatina, and 
yet albuminuria and tube-casts were absent until convulsions occurred, 
with death resulting from oedema of the lungs. In this case, a necropsy 
revealed the presence of acute nephritis. He also reports the case of a 
child dead on the thirteenth day, of malignant scarlet fever, in whom 
repeated tests during life had not shown albuminuria, and yet whose 
kidneys shoAved indubitable evidences of hemorrhagic nephritis. 
Steiner has seen nephritis without dropsy, but never dropsy without 
nephritis after scarlatina. It is altogether probable, however, that in 
many cases the dropsy following scarlatina without albuminuria is sec- 
ondary to concomitant anaemia. This is the view adopted by Hennoch. 
Whatever be the explanation, such cases usually run no remarkable 
course. The general health is not much reduced. The urine is in nor- 
mal amount, the various functions fairly performed. With the dis- 
appearance of the dropsy, convalescence generally becomes established. 

Scarlatinal nephritis is not associated with any especial type or phase 
of scarlatina. It is as frequent after mild as after severe attacks ; in- 
deed, it is possible that the care exercised over those who have had 
grave attacks of scarlet fever, as shown in proper nursing and hygienic 
surroundings, may furnish a safeguard against renal complications. At 
all events, there is a widespread belief that the milder cases are more 
apt to be followed by nephritis and dropsy. Violent nephritis may cer- 
tainly follow a scarlatina so mild as to have escaped observation ; but 
individual predisposition and epidemic type are probably the most im- 
portant etiological factors, though at present not enough is known to 
justify dogmatic statement. 

Scarlatinal nephritis and dropsy may occur without antecedent symp- 
toms of scarlatina. Instances of this are not uncommon, though the 
evidence that supports them is rather circumstantial than direct. 
Several members of a family, or of a school or asylum in which scarla- 

i Berl. klin. Wochensch., 27, 1882. 2 ibid., 50, 1873. 



60 ATKINSON, SCARLATINAL NEPHRITIS. 

tina has been known to prevail, may exhibit the dropsy and albumin- 
uria characteristic of scarlet fever, in whom no previous symptom of the 
disease had been manifested. Such cases run an ordinary course, but 
may at times develop a severity altogether unexpected. 

Pathological Anatomy. — The kidneys of those who die of scarla- 
tina, or of the nephritis consequent upon it, present morbid conditions, 
the often widely differing characters of which depend upon the nature 
and intensity of their exciting causes. Friedlander, 1 in his investigations, 
found three forms of renal inflammation after scarlatina, which are 
sharply defined from each other. These are, 1. Initial catarrhal neph- 
ritis, the early form ; 2. The big, flabby, hemorrhagic kidney, intersti- 
tial septic nephritis ; 3. Glomerulonephritis, nephritis post -scarlatinosa. 
The first, he asserts, appears with the beginning of the exanthema, or a 
few days later, and disappears in a few days or weeks. It rarely excites 
oedema, and hardly ever kills. It is analogous to the alterations pro- 
ductive of the febrile albuminuria of many infectious diseases. The 
kidneys show cloudiness, swelling and proliferation of the tubular epi- 
thelium, and later, fatty degeneration. In the tubular lumen are hya- 
line and granular cylinders, round cells, and desquamated epithelium. 
In the interstitial tissue are scattered round cells. The capsule of Bow- 
man is thickened, and at times there is a small amount of albuminous 
fluid between the capsule and the glomerulus. Micrococci are some- 
times found in the capillaries and tubules. The large, flabby, hemor- 
rhagic kidney was found in 12 of the 229 scarlatinal necropsies made 
by Friedlander. It was found especially when the scarlatina had been 
complicated by severe diphtheria, abscess, etc. It is not characteristic 
of scarlatina, but is also seen in primary idiopathic diphtheria. The 
kidneys are large and soft, and show pronounced cortical changes. The 
cortex is invaded by small extravasations and larger blood infiltrations. 
The epithelium is only slightly altered, but the interstitial tissue is thick- 
ened and abundantly infiltrated with round cells. Emboli of micro- 
cocci are commonly present. The disorder develops between the first 
and fourth weeks, and is so rapidly fatal that oedema has not time to 
develop. It is an especially severe form of septic nephritis. 

Glomerulo-nephritis, Friedlander holds to be the only characteristic 
scarlatinal nephritis. The kidneys in this condition are firm, often hy- 
persemic, and resemble the cyanotic kidney, except that the glomeruli do 
not appear red upon section, but gray and anaemic. They are enlarged 
and prominent. Alterations are almost limited to the glomeruli, which 
are enlarged by one-half. Their nuclei are enlarged, their coils empty 
of blood, their walls thickened, and their lumina contracted or obliter- 
ated. Bowman's capsule is only slightly thickened, as a rule; some- 

1 Fortschritte d. Med , No. 3, 1883, p. 81. 



SCARLATINAL NEPHRITIS. 61 

times it is proliferated. Accompanying conditions are slight interstitial 
cell infiltration, fatty degeneration of epithelial cells, and hyaline forma- 
tion in the arteries. The alterations in the glomeruli easily account for 
the anuria and uraemia, as well as rapid hypertrophy of the left ventricle, 
by their obstruction of the renal arteries, as nearly all of the renal 
arterial blood has first to pass through the glomeruli. Scarlatinal glo- 
merulo-nephritis was first described by Klebs. 1 

Klein, 2 who has given the subject especial attention, in a series of 23 
necropsies of bodies of those dead of scarlet fever, did not observe the 
identical glomerulo-nephritis as described by Klebs. Klein's cases died 
at various periods between 2 and 44 days. Their ages were between 2 
and 36 years, the largest number being between 2 and 12 years old. 
Klein's observations included changes resembling the glomerulo-neph- 
ritis of Klebs, but these were only characteristic of the early stages of 
scarlatina. He divides the changes into those occurring in the early 
and those occurring in the late stages, a definite boundary between them 
not being present. The first set of changes are chiefly limited to the 
cortex. They are, 1. Increase of nuclei (probably epithelial) covering 
the glomeruli. 2. Hyaline degeneration of the elastic intima of minute 
arteries, especially of the afferent arterioles of the Malpighian tufts. 
The intima of these vessels is swollen from place to place into spindle- 
shaped hyaline masses, causing narrowing of the lumen. There is 
similar hyaline degeneration of the capillaries of the glomeruli, causing 
these often to become impermeable. These degenerated parts become 
more fibrous in appearance and Bowman's capsule becomes thickened. 
3. A third change is multiplication of the nuclei of the muscularis of 
the minute arteries with increased thickness of their walls. This is 
most conspicuous at the entrance into glomeruli, but is also distinct in 
other arteries of the cortex and in the base of the pyramids. There are, 
also, swelling of the epithelia of the convoluted tubules and prolifera- 
tion of their nuclei, especially of the tubules close to the afferent arteri- 
oles of the glomeruli. Granular matter and blood may be found in the 
cavity of Bowman's capsule and in the convoluted tubules. In some 
cases there is detachment of the epithelium of the large tubules of the 
pyramids. 

Klein's observations, 1, that the hyaline changes readily affect the 
arteries near their point of branching, and, 2, that the hyaline sub- 
stance is of the nature of elastic tissue, agree with the conclusions of 
Neilson concerning the arteries in various cerebral disorders and in 
many infectious diseases. He does not think that the anuria and 
ursemic poisoning in scarlatina, when the kidney does not show con- 
spicuous change, are due to compression of the vessels of the glomerulus 

1 Handbuch der Path. Anat. 2 Transact. Path. Soc. London, 1877, xxviii. p. 435. 



62 ATKINSON, SCARLATINAL NEPHRITIS. 

by the nuclear germination, as claimed by Klebs. He rather attributes 
these to the changed state of the arterioles, and suggests that the in- 
creased exercise of the arterial muscular tissue under the influence of 
the stimulus supplied by the disease, may cause a contractility which 
affects the calibre of the arterioles and shuts out the glomerulus from 
the circulation, and thus, so far as it operates, suppresses the secretion 
of urine. This hyaline change is seen in other arteries and in other dis- 
eases. The parenchymatous changes found in the early stages are 
slight and in some cases difficult to detect, the cloudy swelling and 
granular degeneration being limited to small portions of convoluted 
tubules. The second order of changes occurred in cases beginning about 
the ninth or tenth day. They were interstitial as well as parenchyma- 
tous. Round cells were found in the connective tissue of the kidneys 
around the large vascular trunks, spreading thence into the base of the 
pyramids and into the cortex. Klein declares that this begins about 
the end of the first week and gradually increases until portions of the 
cortex, very seldom portions of the bases of the pyramids, are converted 
into pale, firm, round cell tissue, in which the original tubes of the cor- 
tex become gradually squeezed and lost. The parenchymatous element 
of the nephritis consists in crowding of urinary tubules ivith lymphoid 
cells, granular and fatty degeneration of the epithelium of the tubules, 
and various kinds of cylinders. This becomes distinct as the interstitial 
changes become pronounced. The infiltration of the cortex with round 
cells begins at the roots of the interlobular vessels, spreading rapidly 
toward the capsule of the kidney, and laterally among the convoluted 
tubules around the glomeruli. At first between the medullary rays, it 
later encroaches upon them and also the subcapsular region. Parts of 
the cortex may thus be converted into whitish, firm, bloodless, cellular 
masses in which Malpighian tufts and urinary tubules become more or 
less degenerated. In one case renal embolism was encountered ; the in- 
terstitial inflammation was very intense, as also the parenchymatous in- 
flammation. The kidney was markedly enlarged. The intensity of the 
parenchymatous inflammation is dependent upon the degree of the inter- 
stitial nephritis. Klein also notes the deposition of lime in the epithe- 
lium and lumina of the tubules, first of the cortex and then of the 
pyramids, at an early stage of scarlatina when only slight changes are 
otherwise shown. Cases of scarlatina, according to Klein, that die after 
the ninth or tenth day, usually show more or less well-marked inter- 
stitial nephritis. 

Treatment. — Though nephritis may arise both in mild and in severe 
cases of scarlatina, in cases where exposure is known to have occurred 
and in those who have been jealously protected from injurious influ- 
ences, there can be no doubt that sudden changes of temperature, strong 
draughts, dampness, etc., are powerful predisposing causes of kidney 



SCARLATINAL NEPHRITIS. 63 

disease after scarlatina. Mahomed declared that a slight chill during 
convalescence is sufficient to cause transitory albuminuria. The patient 
should, therefore, be carefully protected. During the height of the 
disease the daily bath or tepid sponging should be continued, a proced- 
ure through which renal complications are frequently avoided. Even 
the mildest case should be kept in bed for at least a week after the ces- 
sation of fever ; nor should he be permitted to leave his room before the 
expiration of the third week. Out-of-door exercise should not be re- 
sumed in disregard of states of season, of barometric and of thermo- 
metric variations. 

In midsummer, when windows and doors must remain open, the ques- 
tion of outdoor exercise becomes one of danger rather to others than 
of personal risk ; while in spring, fall, and winter the risks of exposure 
are especially great, and in midwinter the patient should not venture 
out before the sixth or seventh week after perfectly normal scarlatina. 
During convalescence, daily warm or tepid baths should be continued 
until the completion of desquamation. Slight albuminuria may occur, 
according to Mahomed, during convalescence, associated with constipa- 
tion and a hard pulse, indicative of high arterial tension, without sub- 
jective symptoms, and remediable by a brisk purge, the renal functions 
being quickly restored. 

Dietary management will go far toward preventing renal complica- 
tions. The observance of a rigid milk diet in all cases of scarlatina is 
regarded by Jaccoud as absolutely preventive of nephritis in scarlet 
fever. Though this may not be a justifiable opinion, it is certain that 
in this disease there is no better diet than one of milk. Should neph- 
ritis arise, it is the more important that the milk diet should be con- 
tinued. From two to three or four pints may be given in small quan- 
tities at brief intervals, during the twenty-four hours, the largest 
amount mentioned being sufficient for an adult without other food. If 
there are reasons why milk cannot be given, light broths and soups are 
more suitable than beef tea and may be administered with wholesome 
farinaceous food. Buttermilk may at times be preferred, and bonny- 
clabber and slip or junket (milk sweetened and flavored and coagulated 
with liquid rennet), are often relished and are excellent articles of food. 

When nephritis forms a feature of rapidly fatal malignant scarlatina, 
it may have no time to develop symptoms, or these may escape observa- 
tion, or the virulence of the disease may have thrown the renal disorder 
into the background or have rendered attempts to treat it futile. In 
milder cases, and later, during the latter part of the first or during the 
second or third week, when nephritis occurs, special attention may be 
devoted to its treatment. 

Proper regard having been paid to the patient's hygienic surround- 
ings and nutrition, a brisk hydragogue cathartic should be administered, 



64 ATKINSON, SCARLATINAL NEPHRITIS. 

if, as is usual, there is a tendency toward constipation. For this pur- 
pose nothing is better than the compound jalap powder. For a child, 
from five to twenty grains of this should be ordered every second night 
or every night, as required, the object being to secure several watery 
actions of the bowels every twenty-four hours. The proper dose for an 
adult is one drachm. The desired watery stools will be most readily 
obtained by the saline cathartics when given in concentrated watery 
solution, as has been definitely shown by the researches of Dr. Matthew 
Hay. The more drastic purgatives will rarely be required except in 
uraemic intoxication and in extreme dropsy, when podophyllin, croton 
oil, elaterin, etc., may occasionally be employed with benefit. When 
dropsy is but slightly pronounced, purgation may not be required. 

The proper action of the bowels being provided for, the establishment 
of diaphoresis and healthy skin action will demand attention. Fre- 
quently during the day the body may be wrapped in flannels, wet 
or dry, as hot as can be borne, or the pack may be applied. When 
available, the steam bath or hot-air bath is to be strongly recommended. 
Excellent results may also be secured from the hot plunge-bath. Pilz 
has especially lauded this treatment. It should be used after the method 
of Liebermeister, by gradually increasing the temperature of the bath 
from 36° C. to 40° C. (96°-104° F), in a half hour. Under its use 
the drojDsy rapidly disappears. Diseases of the heart or lungs, while 
not positively contraindicating this plan of treatment, necessitate great 
caution in its application. Every precaution against sudden chilling of 
the surface must be observed. 

The kidneys demand the greatest consideration. The imminence of 
danger is usually proportionate to the impairment of their function. In 
giving remedies directly to modify the action of the kidneys, none calcu- 
lated to increase their hyperemia should be employed. On this account, 
the stimulating diuretics should be avoided. Exception can hardly be 
made in favor of juniper, which enjoys, with some writers, considerable 
reputation in scarlatinal nephritis ; but digitalis, the pharmacological 
position of which is not as yet definitely determined, has received very 
general approval as a most useful diuretic in acute nephritis. The 
infusion is by all odds the best preparation of digitalis when its diuretic 
properties are desired, and may be given in doses of from one fluid- 
drachm to a half fl uidounce, according to age, three or four times daily. 
Its effects are, however, hardly as happy as when dropsy is associated 
with or dependent upon cardiac weakness. Those diuretics that act 
specifically upon the secreting cells of the urinary tubules, the sedative 
or refrigerant diuretics, are, as a rule, to be preferred in the treatment 
of scarlatinal dropsy, and will often effect the most astonishing results. 
Of these the salts of potash are most efficacious, the citrate, acetate, 
bitartrate, and bicarbonate. In cases of slight nephritis and anasarca, 



ATKINSON, SCARLATINAL NEPHRITIS. 65 

a lemonade made with bitartrate of potash will be taken with avidity, 
and will often almost magically increase the quantity of urine, reduce 
the dropsy, rapidly diminish the albuminuria, and cause a radical 
change for the better. This lemonade may be made by adding one 
drachm of cream of tartar to a pint of boiling water into which a lemon, 
cut into thin slices, has been dropped. This quantity, properly sweet- 
ened, may be drunk during the day by a child five years old. Water 
may be allowed freely, and any of the mild domestic infusions may be 
substituted for it, their virtue residing principally in the amount of 
fluid. Dickinson especially commends the free use of water as unirri- 
tating and tending to wash out of the tubules the exudated matters that 
choke up their lumina. 

In more severe cases, where life is threatened through one or another 
of the various features of uraemia, most energetic treatment will 
be required. Jaborandi may now prove useful. J. Lewis Smith 
speaks of it in terms of highest praise, and quotes Hirschfeld's com- 
mendation of its action. To a child two years old one-twentieth of a 
grain of pilocarpin may be given by the mouth every fourth or sixth 
hour, or the same amount may be injected hypodermatically. Both 
diuresis and diaphoresis will be promptly increased, and in favorable 
cases the ursemic symptoms disappear. Ursemic coma and convulsions 
developing suddenly or only after progressive renal embarrassment, 
should be treated without reference to the scarlatina and upon general 
principles. A remedy of most undoubted value, at least for the control 
of convulsions, is chloral, which, if the patient be unable to swallow, 
may be injected in full doses under the skin or into the rectum. Under 
its influence convulsions will often speedily cease. 

After the more acute nephritis has subsided and convalescence 
promises to become established, iron becomes one of our main reliances, 
both through its hsematic and diuretic properties. The tincture of the 
chloride is the most appropriate preparation in some cases, but, in 
general, the mistura ferri et ammonise acetatis of the pharmacopoeia 
will produce the best results. Quinine is also a remedy of great value 
in the treatment of convalescence from scarlatinal nephritis. 

During the height of the inflammation, local treatment is often of 
great importance. If the fever is intense, the pulse full and strong, 
and if pain and tenderness in the back are pronounced, the abstrac- 
tion of blood, by leeches or cups, from the loins, will, beyond doubt, 
often prove beneficial. Large poultices and sinapisms may also often 
be applied over the kidneys, and besides assuaging the irritation, tend 
to promote diaphoresis and diuresis. For obvious reasons turpentine 
should not be employed as a counter-irritant in these cases. Occa- 
sionally ascites may be so excessive that the pressure exerted upon the 
kidneys interferes with the action of therapeutic agents and impedes 

NO. CLXXXIII.— JULY, 1886. 5 



66 CHEYNE, BACTERIOLOGY. 

the functional activity of these organs. Paracentesis abdominis, by 
relieving this compression, will often be followed by copious diuresis 
and the rapid disappearance of general anasarca. Cases of scarlatinal 
nephritis will, unfortunately, sometimes pass into chronic Bright's 
disease, and then will require the usual treatment for this condition. 
19 Cathedral Street. 



BACTEEIOLOGY. 
By W. Watson Cheyne, M.B., F.R.C.S., 

ASSISTANT SURGEON TO KING'S COLLEGE HOSPITAL, SURGEON TO THE PADDINGTON GREEN CHILDREN'S 

HOSPITAL, ETC. 

The rapid advances of bacteriology during the last few years, and 
the important role which bacteria play both in health and disease, render 
unnecessary any apology for the publication in a journal devoted to the 
medical sciences of a sketch of the chief facts which have been made 
out with regard to these microorganisms and of the methods of investi- 
gation employed in their study. A knowledge of what has been discov- 
ered with regard to these minute bodies is essential for the study of 
pathology, and for the rational treatment of infective diseases. But it is 
more especially in the department of preventive medicine that the prac- 
tical value of these researches is as yet evident. So long as the precise 
cause of a disease is unknown, the views held as to its origin must neces- 
sarily be vague, and the measures adopted against it often either ineffi- 
cient or excessive. But when the cause is known, and more especially 
when it can be studied apart from the body, its life history, its habitat 
outside the body, its mode of entrance into the system, and the best 
methods of destroying it under various conditions are learned, and the 
measures to be adopted against it can be made precise and effectual. It 
is not, however, sufficient for the medical officer of health to know the 
literature of the subject; he must himself be a bacteriologist, ready and 
able at any moment to carry out an investigation on bacteria. More 
especially must he be acquainted with the methods of demonstrating, 
recognizing, and studying these organisms in water, food, etc., with the 
view of determining in many cases whether these substances are hurtful 
or not, and also with the view of ascertaining the exact source and com- 
mencement of any given epidemic. The importance of this knowledge 
is self-evident, and I need not do more than point out one striking 
example of the value of being able to ascertain the earliest cases of an 
epidemic disease. The diagnosis, clinically or by post-mortem examina- 
tion, of an isolated case of Asiatic cholera has, up till recently, been very 
difficult, or almost impossible ; it is, as a rule, only after the epidemic is 



CHEYNE, BACTERIOLOGY. 67 

established that the nature of the disease is known. But it is admitted on 
all sides that, if the first case be recognized, measures can be taken which 
may prevent the spread of the disease, provided that contamination of 
some common source of food or water supply has not been the cause of 
this first case — in other words, provided that the first infection has come 
from without, and not from some source common to the other inhabitants 
of the place. Now, by the use of the recent methods of cultivation, the 
diagnosis can be readily made by ascertaining the presence or absence 
of Koch's cholera bacilli in the dejecta of the patient. A grave respon- 
sibility rests on every sanitary officer who does not know how to demon- 
strate and recognize these organisms. In fact, I consider that every 
candidate for a qualification in sanitary science should be required to 
show a practical knowledge of the receut methods of research, as well as 
a thorough acquaintance with the literature of the subject. It is neces- 
sary that the practising physician also should be, to a certain extent, 
versed in some of the methods, more especially in those of staining and 
examining bacteria, as, for example, the bacillus of tubercle, in order to 
enable him to make or confirm his diagnosis. In surgical work, again, 
more especially in the treatment of wounds, a practical acquaintance 
with the subject is almost essential. Whatever antiseptic substance be 
employed, or whatever method of w T ound treatment be adopted, the 
principles enunciated years ago by Sir Joseph Lister must be rigidly 
adhered to : microorganisms must be completely excluded from wounds 
or their active development must be prevented. To do this intelligently, 
the surgeon must know what are the chief facts with regard to bacteria; 
while, to carry out wound treatment comfortably and successfully, a 
practical knowledge of the methods employed in laboratory researches 
is almost essential. To the surgeon unacquainted practically with 
these methods, the details of treatment must be irksome, and conse- 
quently often imperfectly carried out ; while to him who has worked 
with these organisms in the more difficult laboratory experiments, the 
manipulations necessary in surgical treatment become almost instinctive. 
The importance of these studies will doubtless become more fully recog- 
nized as time goes on, and facilities for their study by students will be 
provided in every good teaching school, as is, indeed, being already 
rapidly done in the leading universities in Germany. 

The bacteria belong to the lowest forms of life, and for a long time 
were included in the animal kingdom. The study, however, of their 
morphological and physiological characters, their modes of reproduction, 
and the close relations which they evidently bear to the algse (to certain 
of the phytochromacese more especially) on the one hand, and to the 
lower fungi on the other, have led observers to look on them as the 
lowest stage of plant life. 

They consist of single cells, which may remain isolated or become 



68 CHEYNE, BACTERIOLOGY. 

united together in rows or groups. The cells may be of various shapes 
and sizes, but there are three chief morphological types which have led 
to the provisional subdivision of the bacteria into three great classes. 
In some bacteria the individual cells are round or slightly oval ; these 
are termed cocci (Fig. 1, a, f, g), and are subdivided into micrococci 




a. f, g. Micrococci, a, staphylococci ; /, streptococci ; g, diplococci. 

b. Short bacilli (bacteria, Colin). 

c. Long bacilli (vibrio). 

d. Spirillum. 

e. Spirochreta. 

h. Comma-bacilli (intermediate between bacillus and spirillum). 

and megacocci, or according to their arrangement into staphylococci 
(Fig. 1, a), streptococci (Fig. 1,/), ascococci (Fig. 3, d), etc. The term 
micrococcus is, however, generally applied to the whole group. Again, 
the cells may be more or less elongated, varying from short rods which 
are twice as long as broad, to long threads ; these are the bacilli (Fig. 
1, b, c). This second class was divided by Cohn into two: the bacteria 
proper, where the cells are small and short, and do not form chains or 
threads (Fig. 1, 6), and the thread bacteria, where the individual cells 
are longer and remain connected together so as to form chains and 
threads, these being again subdivided into the bacilli, where the threads 
are straight, and the vibriones, where the threads are wavy (Fig. 1, c). 
This subdivision has not, however, been found to be practicable, for 
under some circumstances a rod may be so short as to deserve the name 
bacterium, while under other conditions it may become so much longer 
as to require the term bacillus. Hence it is best to include both of 
Cohn's divisions in the one class, bacillus. In the third class the organ- 
isms are elongated and twisted like a corkscrew. These are termed by 
Cohn, spiro-bacteria (Fig. 1, d), and by him are subdivided into two 
forms — the spirochetal (Fig. 1, e), where the rod is flexile and long, and 
the turns of the screw close together ; and the spirilla proper (Fig. 1, d), 
where the rod is stiff, shorter, and the turns of the screw wider apart. 
The whole class of spiro-bacteria is now generally spoken of as spirilla. 
As intermediate or transitional forms between bacillus and spirillum, we 
may reckon the various comma-shaped organisms found by Koch, Finck- 
ler, Deneke, etc. (Fig. 1, k), and also the organisms formerly called 



69 

vibriones. The various classifications of the bacteria will be considered 
afterward, for the present we will speak generally of the three groups 
which have been referred to, the micrococci, the bacilli, and the spirilla. 

These cells consist of a mass of protoplasm in which as yet no nuclei 
have been discovered enclosed in a cell wall, and sometimes surrounded 
by a gelatinous material or capsule. 

The protoplasm in the smaller bacteria appears to be homogeneous, 
but in several of the larger forms, in the spirilla especially, it is finely 
granular, while in some it contains coloring matter, starch, and fat 
granules, etc., as will be mentioned immediately. It may be arranged 
equally throughout the cell, or it may be collected in masses at various 
parts of the interior ; at any rate, the latter appearance is often presented 
after staining. In the micrococci the protoplasm of the coccus is appa- 
rently homogeneous throughout, but in many bacilli, on the other hand, 
it presents a beaded appearance. This is especially well seen in stained 
specimens of the tubercle bacillus where from four to eight of these 
beads are generally present in one rod, each bead being connected by a 
narrow line of deeply stained protoplasm. By suitable illumination of 
the specimens, the same beaded appearance can be demonstrated in a 
number of bacilli. Its occurrence may be due to some extent to the 
action of the reagents employed ; but I think that, on the whole, it must 
be held to indicate a certain differentiation in the structure of the cells. 
It may indicate either the accumulation of the protoplasm at various 
parts of the rod, leaving only a small quantity in the intervening por- 
tions, or a different chemical composition of the protoplasm in different 
places. Possibly, in some cases the first, iu others, the second explana- 
tion is the proper one. Thus in the tubercle bacillus (Fig. 2, a), and in 
several other bacilli, the cell wall forms a continuous tube of equal 




a. Tubercle bacilli. 

b. Cholera bacilli. 



calibre containing the beaded protoplasm : here, probably, the second 
view would apply. In other cases the cell wall seems to be pinched in 
on each side of the beads, indicating the presence of a smaller amount of 
protoplasm at these places (Fig. 2, b). This appearance must not be 
confounded with division of the cells, from which it may be readily dis- 
tinguished, chiefly by the fact that a continuous tube can be seen outside 
the beads, and also by the fact alluded to that the stained protoplasm 
is often continuous from one bead to the other, and is not completely in- 
terrupted, as is the case where two bacilli join one another. Nor must 



70 CHEYNE, BACTERIOLOGY. 

the clearer intervals be looked upon as spores, for which they have often 
been mistaken from the fact that spores do not take on the stain when 
subjected to the same process as the rods. Spores are round or oval 
bodies ; the clear spaces alluded to here are biconcave. 

As to the nature of this protoplasm very little is known, but from its 
chemical reactions it is evidently closely allied to the protoplasm of 
other cells. Judging from its reaction with the aniline dyes the proto- 
plasm of most bacteria most nearly approaches in its chemical charac- 
teristics that of the nuclei of cells, for the same method of staining 
with aniline colors which is employed for certain bacteria in tissues, 
will also stain the nuclei of the tissue cells. On the other hand, it is 
not identical with nuclear protoplasm, for other substances which will 
stain the nuclei of cells will not stain bacteria. Again, the protoplasm 
of different bacteria differs in composition, as shown also by the effect 
of staining reagents. Thus, methods of staining which will stain an- 
thrax bacilli will not stain the bacilli of tubercle and syphilis — at any 
rate, not so intensely. The chief researches on the composition of the 
bacteria have been carried out by Nencki. 1 According to him, the 
actively growing bacteria contain 83.42 per cent, of water. Of the 
remainder, 84.2 per cent, consists of an albuminous substance, 6.04 per 
cent of fat, 4.72 per cent, of ash, and 5.04 of undetermined materials. 
The albuminous substance is called by Nencki mijcoprotein, and differs 
from other proteid substances in its composition. It contains 53.32 per 
cent, of carbon, 14.75 per cent, of nitrogen, 7.55 per cent, of hydrogen, 
and probably neither sulphur nor phosphorus. Analysis of other 
bacteria by Nageli and Low gave somewhat different results. 

Bacteria have always been considered to be devoid of chlorophyll, 
but Van Tieghem has described an organism which he reckons among 
the bacilli, and calls bacillus vlrens, which has a green color due to the 
presence of this substance.''' Some bacteria, when growing in colonies, 
give rise to masses of various colors. These are called the chromo- 
genous bacteria. It is difficult to say whether the coloring matter in these 
cases is present in the protoplasm of the cell, in the inner cell membrane, 
or in the material which unites the cells together. In some large 
organisms — for instance, in the beggiatoa rosea-persicina of Zopf — the 
pigment is apparently present in the protoplasm of the cells in a dis- 
solved state, but in most cases the cell protoplasm is probably free from 
pigment. Some bacteria give a reaction of starch. According to Van 
Tieghem, a form of spirillum (spirillum amyliferum), and according to 
Trecul, the bacillus amylobacter (bacillus butyricus) contain granules which 
give the starch reactions. This starch is not only present when the 

1 Nencki, Journal fur prakt. Chem., N. F., Bd. 23, and other works. The facts here mentioned are 
quoted from Fliigge, Fermente und Mikroparasiten, 1883. 

2 See De Bary, Vorlesungen iiber Bacterien, 1885. 



CHEYNE, BACTEEIOLOGY. 71 

organisms are growing in a solution containing starch, but also when 
starch is absent from the food. This reaction is apparently only present 
at certain stages of growth of the organisms. The beggiatoa which 
grow in various waters, more especially in sulphur springs, contain at 
certain periods of their growth granules of sulphur, sometimes of con- 
siderable size. 

The cell wall can be readily demonstrated by various reagents, and in 
the case of most bacteria is said to contain a carbohydrate closely allied 
to cellulose. This is especially the case in the non-putrefactive bac- 
teria, such as the bacterium aceti, but Nencki and Schaffer assert with 
regard to the putrefactive bacteria, that the wall consists of mycopro- 
tein like the contents. This membrane is generally flexible, but in 
some, especially in the spirilla, it is apparently rigid. 

Some bacteria, when single or in pairs, are surrounded by a gelat- 
inous material forming a capsule. This is perhaps best seen in Fried- 
lander's pneumococcus (Fig. 3, a). In it the cocci occurring singly, in 






a. Pneumococcus with its surrounding capsule. 

b. Micrococcus tetragenus, with capsules. 

c. Zoogloea formed by bacilli. 

d. Ascoccus, clumps of micrococci embedded in a gelatinous mass. 

pairs, or chains of three or four, are surrounded by a broad capsule 
which takes on the aniline stain faintly. This material swells up and 
apparently dissolves in water, and hence in pneumonic sputum the capsules 
cannot be satisfactorily demonstrated. Similar capsules are rare in the 
case of isolated bacteria, but they have been described in other instances, 
as in micrococcus tetragenus (Fig. 3, b), in the bacillus of blue milk, etc. 
In other cases the bacteria do not remain isolated, each surrounded by its 
own capsule, but they adhere together, forming what are termed zoogloea 
masses, the gelatinous material uniting together large numbers of bacteria 
in balls, or more generally in the form of skins or scums on the surface 
of the materials on which they grow (Fig. 3, c and d). The form of 




'" -vj 



,.,,,. 



72 CHEYNE, BACTERIOLOGY. 

these scums or masses differs in different bacteria, so that different species 
may be recognized by this alone. The formation of zooglcea occurs 
only at certain stages of the life of the organism, and in the case of the 
motile bacteria is preceded by a stage during which the organisms move 
freely in the fluid in which they are growing. It is a question whether 
this gelatinous substance is an excretion from the cell or only the outer 
layers of the cell-wall which have swollen up and become gelatinous 
(Zopf ). It gives, according to Zopf, the reaction of mycoprotein in the 
putrefactive bacteria, but that of cellulose in those concerned in other 
fermentations ; in both instances it contains a large amount of water. 

Some bacteria are always motionless, others, for part of their life at 
any rate, swim about more or less rapidly in fluids, often becoming 
motionless at a later stage. In the latter case, when they become 
motionless they generally form a scum on the surface of the fluids in 
which they grow. As to the micrococci, it is doubtful whether or not 
they have the power of movement. Most writers regard the motion 
seen in the micrococci as entirely brunonian, but I am inclined to think 
that they may also have the power of spontaneous movement, for when 
sown in a flask containing a suitable nutritive fluid the latter very soon 
becomes quite turbid throughout, which could hardly happen were they 
entirely devoid of motion. Were that the case, they would naturally 
fall to the bottom and form a sediment, as is seen in the case of the 
motionless anthrax bacillus, which forms flocculent masses at the bottom 
of the flask, while the upper part of the fluid remains quite clear. 
Ogston has also described the movement of chains of micrococci ob- 
served under the microscope. In corroboration of this view is the state- 
ment made by Mr. E. M. Nelson, who is well known as a most expert 
microscopist, that he has seen micrococci with flagella, usually one to 
each coccus. I have seen his specimens, and certainly it looks very 
much as if flagella were present. Zopf also describes cilia in connec- 
tion with cocci, especially in connection with what he holds to be the 
coccus stage of cladothrix and beggiatoa. 

The character of the movements exhibited by bacteria in fluids is 
extremely diverse. Some have an oscillating pendulous movement, 
others whirl rapidly around their axis or dart forward and backward, 
while the spirilla again have a corkscrew motion. How the movements 
are brought about is not clear, and probably the mechanism is not the 
same in all cases. In some the motion seems to be due to contractions 
of the protoplasm of the cell itself, a sort of eel-like action. In others it 
may possibly be due to the flagella which have been seen in connection 
with them (Fig. 4). In several of the larger bacteria, and also in some 
of the smaller forms, long flagella can be seen at one or both ends of 
the rod. There is usually one at each end (Fig. 4, a and c), but Warm- 
ing has described spirillar forms with two at each end, and in what he 



CHEYNE, BACTERIOLOGY. 73 

looks on as a spiral form of beggiatoa roseo-persicina (ophidomonas san- 
guined) he has found three at one pole (Fig. 4, b). In many motile 
bacteria no flagella have been demonstrated, and, supposing that they 
are present, this negative result might be due to two causes ; either to 
retraction of the flagella during the process of preparation, or to the 

Fig. 4. 




/-\ 



a. Spirillum with cilia. 

b. Spirillum with two cilia at each end, and one with three cilia at one end (ophidomonas ; Warming). 

c. Cholera bacillus with cilia. (From a drawing by Mr. E. M. Nelson.) 

extreme fineness of the object, requiring very accurate illumination and 
very high-angled and well-corrected lenses to demonstrate them. The 
flagella are said not to take on the aniline dyes, but I think they do in 
some cases, though very faintly; they stain brown with a strong watery 
solution of logwood. Zoj3f believes that these flagella are directly con- 
tinuous with the protoplasm of the cell (not with the cell wall), and 
that they can be retracted into the interior of the cell through an 
opening in the wall. They are thus, according to him, contractile 
structures. This view is founded chiefly on analogy with the active 
forms of the algse, but Zopf has also directly observed retraction of the 
flagella on the application of reagents in the case of a form of beggiatoa 
roseo-persicina. Van Tieghem thinks that these flagella are simply 
elongated portions of the cell wall, and therefore not contractile struct- 
ures nor organs of motion. The probability, however, is that they are, 
in many instances, really motile organs. 

Bacteria increase in number mainly by fission. The cell enlarges, 
and after it has attained a certain size, a septum passes in from the 
sheath, dividing the protoplasm into two parts. The two cells thus 
formed may remain connected together or may separate and lead an inde- 
pendent existence, each giving rise again to new cells by a similar process. 
When they remain connected together they may continue to grow and 
divide, thus giving rise to long threads composed of a number of cells 
joined together. The young cells are not so long as the average adult 
organism. Thus, in the case of the bacillus alvei the average length of 
the rod is y^Vo" tn 0I> an inch. These rods continue to increase in length 
till they have attained the -soV^h of an inch, when fission begins in the 
middle. Hence the newly formed young cells measure about yuFoirth 



74: CHEYNE, BACTERIOLOGY. 

of an inch in length. In the bacilli the division always occurs at right 
angles to the long axis of the thread. There is no evidence of longitudinal 
division in the ordinary forms of bacilli, but in closely allied organisms 
(beggiatoa, crenothrix, and cladothrix), which are by some, among 
others by Zopf, reckoned among the bacteria, longitudinal division has 
been seen to occur after repeated transverse division of the rods. In the 
micrococci the division may occur always in one direction, giving rise to 
long chains of cocci (streptococci), and these may form groups by twist- 
ing and interlacing of the chains. In other cases one coccus may split 
into four by division in two directions — transversely and longitudinally ; 
and when these new cocci remain in connection with each other, small 
or large masses are formed (staphylococci). In the case of the sarclnw the 
division occurs not only in two directions (transversely and longitu- 
dinally), but also in a third direction, so that one cell divides into eight, 
and thus a number of packets are formed. When division of cocci first 
occurs the opposed surfaces are naturally not round, and in some micro- 
cocci, especially the gonococci, they may remain for a long time flattened. 
In others, however, they rapidly become rounded off. 

Growth of bacteria by budding, in the same way as occurs in the torulse, 
is denied ; but I have seen appearances in specimens of bacillus alvei 
which lead me to believe that this mode of growth may occur in the 
bacteria also. 1 In growth of bacilli by fission the rod elongates and 
having attained a certain size, it divides into two comparatively equal 
portions, but in the case to which I now allude, a full sized rod is seen 
with a small, somewhat conical knob attached to one end, and separated 
from the rod by a marked division (see Fig. 6, b). 

Many bacteria, more especially the bacilli, form endospores. These 
correspond to the seed of higher plants in function and general properties. 
The spores of bacteria have a wonderful power of resisting the action of 
agencies which would destroy the adult or actively growing organisms. 
They thus provide for the reappearance of the organisms should the 
conditions become, for a time, unfavorable for their active growth. These 
spores retain their vitality in a dry state for a long time, and they resist 
the action of heat and chemical reagents in a striking manner. Thus a 
five per cent, solution of carbolic acid destroys the vitality of adult 
actively growing organisms in a few seconds, but must act for some hours 
before it kills spores. 

When unstained bacteria containing spores are examined under the 
microscope, the latter appear as small, round, or oval, bright, highly 
refracting bodies in the interior of the rod. If the spore-bearing bacteria 
are dried on cover-glasses and stained, say with a watery solution of 
methyl-violet, the protoplasm of the rod takes on the violet stain, but 

1 Journal of the Microscopical Society of London, August, 1885. 



CHEYNE, BACTERIOLOGY. 75 

the fully developed spore remains colorless. It is, however, possible to 
stain the spores of some bacilli, such as anthrax bacilli, in various ways, 
for instance, by immersing the specimen in a warmed solution of the 
fuchsin stain employed to stain tubercle bacilli, washing in dilute nitric 
acid, and staining with methylene-blue. The adult bacilli become blue, 
the spores retain the red color. This, and the other methods of staining 
spores, will be described later in greater detail. 

The spores are shorter than the rods in which they form, but they are 
sometimes as broad (Fig. 5, c), or even broader (Fig. 5, d). They are 
round or oval in shape. There is generally one in each rod. They may 
be placed at one end of the rod or in the middle, or in some cases one 
at each end. In the moving bacteria, especially in those which form a 
scum, the commencement of spore formation is generally preceded by 
quiescence of the organism, but this is not universally the case. In 
bacillus alvei, for example, bacilli containing almost or apparently quite 
fully developed spores can be seen swimming about actively in the cultivat- 
ing liquid. They appear generally when the bacilli have exhausted the 
nutriment in the material in which they are growing, but it is probable, as 
De Bary thinks, that the cause of their formation may also be that they 
have produced substances in the course of their development which check 
further growth, and lead to this provision being made against the entire 
destruction of the organism. Temperature has, however, much to do 
with the formation of spores in many cases. Many bacilli form spores 
readily enough at a low temperature, such as 16° C. or 17° C, but in the 
case of some organisms, spore formation occurs much more luxuriantly 
at the temperature of the human body. The pabulum on Avhich they 
are growing, as well as many other unknown conditions, has also much 
influence. Thus the anthrax bacilli do not form spores inside the living 
body, while according to Ehlers the bacilli of symptomatic anthrax 
(Bauschbrand) form them only inside the body. 

I have been able to study the development of spores in bacillus alvei, 
and other bacteria, by a very simple method, which is equally applicable 
to the study of the mode of development of other forms. Sterilize a 
number of cupped slides by placing them in a beaker plugged with cot- 
ton-wool, and expose them to a temperature of 140° C. for three hours. 
Prepare also a number of cover-glasses by passing them several times 
through a Bunsen flame, and place them on a sterilized glass plate be- 
neath a glass shade. Inoculate a flask of sterilized meat infusion or 
other suitable cultivating fluid from a cultivation containing only bacilli 
and no spores. Place this flask in an incubator, at about 100° F., for 
two or three hours. During that time the bacilli, which swim freely, 
become distributed pretty equally throughout the fluid, and also mul- 
tiply to a certain extent. By taking drops of equal size after thoroughly 
shaking the flask, each drop will probably contain about the same num- 



76 CHEYNE, BACTERIOLOGY. 

ber of bacilli. A very minute quantity of fluid may be obtained by 
means of a syringe having a fine screw on its piston, and a large nut 
revolving on this screw. The quantity of fluid to be used is placed on 
the centre of the sterilized cover-glass, which is then rapidly inverted 
over the glass cell, a little vaseline being run round the edge to prevent 
drying. A number of slides are prepared in this way at the same time, 
and are then placed in an incubator kept at the temperature of the 
human body. From time to time slides are removed from the incubator, 
the cover-glasses rapidly taken off, turned upside down and dried. When 
dry, they are stained with suitable dyes, such as a watery solution of 
methyl-violet, and are mounted as permanent specimens. They can 
thus be studied at leisure, and the results obtained in this way are of 
course much more precise and free from error than when the observa- 
tions are made on unstained specimens where the bacilli are swimming 
about in the fluid. At the same time the specimen can be examined 
immediately after removal from the incubator, if one wishes to see the 
condition of the living bacilli. In order to get full knowledge of the 
cycle of development of an organism, it is necessary to have a series of 
specimens taken at different times and showing the different stages. 
Hence the necessity for starting with the same quantities of the nutrient 
fluid, and the same number of bacilli ; because, to take the instance of 
the formation of spores, whether this be due to exhaustion of the pabu- 
lum or to accumulation of the products of growth, it occurs when the 
bacillar development has reached a certain height. Hence, if in one 
specimen there are, to start with, more bacilli and less fluid than in 
another, spore formation will begin earlier in the former than in the 
latter, and thus the changes seen in the series of specimens will not be 
in proper sequence. I have found that by using three-fifths of a minim, 
calculated to contain one bacillus, and keeping the specimen at 36° C, 
the earliest appearance of spore formation was evident in the bacillus 
alvei in forty-one hours. 

In specimens prepared in this way the first thing noticeable is that the 
rod begins to swell in its middle, and thus becomes spindle-shaped 
(Fig. 5, d, 3). This swelling, which in bacillus alvei generally affects 
the middle of the rod but may in some cases be most marked toward 
one end, increases in size (Fig. 5, d, 2), and the centre gradually ceases 
to take on the stain (Fig. 5, d, 4, 5). This unstained part becomes 
more clearly defined and surrounded by a capsule formed from the outer 
part of the protoplasm. Three or four hours later the rest of the rod 
is seen to have almost, or entirely disappeared, leaving the spore lying 
free in the fluid or enclosed within the remains of the original bacillus, 
which are faintly indicated (Fig. 5, d, 6). Of course, where the spore is 
not thicker than the rod in which it is formed, the bulging of the rod is 
not observed, but a mass of protoplasm seems to become separated in the 



CHEYNE, BACTERIOLOGY. 77 

centre, and gradually to lose its power of taking on the stain. Many 
observers think that the difficulty in staining the spores is due solely to 
their being surrounded by a capsule impermeable to the stain, but this 
I very much doubt. I think it more probably indicates a difference in 

Fig. 5. 




a. Leuconostoc, showing three enlarged cells (arthrospores). 

b. Leuconostoc. 

c. Bacillus anthracis, showing endospores. 

d. Development of endospores in bacillus alvei. 1, the adult rod ; 2 and 3, swelling of the rod at the 
seat of the spore ; 4, 5, and G, gradual differentiation of the spore. 

the chemical constitution of the protoplasm of which the spore tissue is 
composed, for, as will be seen afterward, when the spore begins to sprout 
it gradually acquires the power of taking on the stain, although the cap- 
sule remains apparently unaltered and is afterward shed in its entirety. 
In the unstained specimens the protoplasm appears more opaque, or 
finely granular, at the point where the spore is being formed, and in the 
case of bacillus amylobacter, the granulose reaction is said to disappear at 
that part of the rod. Zopf says that the first stage of the formation of 
spores is a contraction of the protoplasm of the cell which accumulates 
at the part where the spore is being formed. This is, however, not ex- 
actly the case, as shown by the stained specimens, where the ends of the 
rod which do not take part in the spore formation stain as usual, and 
apparently contain as much protoplasm. The formation of the spore is 
therefore due to a change occurring in a definite part of the protoplasm 
of the cell. The formation of endospores has, as yet, been observed only 
in the bacilli. Some authors speak of the occurrence of endospores in 
cocci and spirilla, but this is very doubtful. 

The spores thus produced may lie dormant for an indefinite length of 
time, though apparently there are differences in resisting power between 
spores of different bacteria. When supplied with a suitable soil and 
temperature they sprout and give rise again to the adult bacteria. I 
have studied this change in the spores of bacillus alvei in a manner 
similar to that described above (Fig. 6, a). Drops of cultivating fluid 
were placed on a series of cover-glasses ; they were then inoculated with 
spores of this bacillus, inverted over glass cells, sealed with vaseline and 
placed at the temperature of 36° C. Slides were removed at various 



78 CHEYNE, BACTERIOLOGY. 

intervals of time, the fluid rapidly dried on the cover-glass, stained and 
mounted in Canada balsam. In this case, where one wishes to study 
only the sprouting of the spores, it is not necessary to have the same 
quantities of fluid and the same number of spores in all the specimens, 
for if sufficient and suitable nutriment is present and a proper temper- 

Fig. 6. 

a. 1 to 4, show sprouting of the spores of bacillus alvei ; 5, an empty spore capsule. 

b. Bacillus alvei, showing an appearance of budding. 

c. Bacillus subtilus, showing sprouting of spores. (After De Bary.) 

ature is maintained, the spores must sprout and probably they always 
take about the same length of time to do so. The first change which 
is observed in these specimens is that in many cases the outline of the 
rod in which the spore was formed becomes faintly visible (Fig. 6, a, 2). 
This can be seen in fifteen minutes, and is, I think, simply due to swell- 
ing by the fluid, as it is also evident to some extent in spores soaked in 
water for the same length of time. The next thing that is observed is 
that several of the spores take on the methyl-violet stain and become as 
intensely violet as the adult bacilli (Fig. 6, a, 3). The number of the 
spores which take on the stain in this way goes on increasing as time 
passes, till in about four hours almost all the spores stain violet. In 
three hours the first indication of the sprouting of these spores is seen. 
The stained part of the spore loses its oval shape, becomes elongated, 
and is soon seen to burst through the spore capsule at one end. It then 
presents the appearance of a short rod with a pale envelope embracing 
one end (Fig. 6, a, 4). This rod bye and bye leaves the spore capsule 
altogether and goes on multiplying as a full-grown bacillus. In speci- 
mens taken after four or five hours all stages of growth can be observed, 
and the remains of the ruptured spore capsules are seen partly attached 
to the ends of rods and partly lying about the field (Fig. 6, a, 4 and 5)'. 
The sprouting of spores has also been studied, without staining, by 
Prazmowsky and others. The spore first loses its highly refracting 
appearance, becomes granular, elongates, and bursts through its spore 
capsule. In the case of bacillus butyricus the rod also passes out of one 
of the ends of the spore, but, according to De Bary, in bacillus mega- 
terium and bacillus subtilis it bursts through the middle of the spore and 
then bends at right angles so as to follow the direction of the original 
rod (Fig. 6, c). 

De Bary classes all the bacteria which do not produce endogenous 
spores as arthrosporacese. That is to say, certain cells of the colony 



CHEYNE, BACTEEIOLOGY. 79 

or chains of bacteria take on the qualities of spores, so as to serve as 
starting-points for fresh generations. It is doubtful whether there is 
much advantage in this division, for it is impossible, in many cases, to 
distinguish these cells from the other vegetative cells, and there is no 
evidence with regard to the ordinary bacteria that any of the cells in a 
colony of bacteria, which do not form endogenous spores, take on qualities 
different from the other vegetative cells, such as greater resisting power, 
different reaction with staining reagents, etc. The only cases in which 
the existence of bodies which must be looked on as arthrospores is proved, 
are the cases mentioned by De Bary, viz., leuconostoc and bacterium zopfil 
to which he also adds crenothrix, cladothrix, and begglatoa. Leuconostoc 
consists of curved rows of round cells surrounded after a time by firm 
and extensive gelatinous masses (Fig. 5, b). After a time the greater 
number of cells in the chain die, but some cells retain their vitality, 
attain a somewhat larger size than the others, ultimately, by the solution 
of the gelatinous material, become free, and then serve as starting-points 
for new growths (Fig. 5, a). It may, of course, be that a similar thing 
occurs in all bacteria which do not produce endogenous spores, but at 
present it is a pure assumption that this is the case. 

In addition to these modes of growth, various abnormal forms occur 
toward the end of the life of bacteria, which are not vegetative but 
involution stages. Chief among these forms are swellings of the rods, 
and they may be seen in most forms of bacilli after they have been cul- 
tivated for a long time without fresh addition of nutriment. 

From the mode of growth of these minute organisms we must pass on 
to the consideration of the conditions which favor or hinder their de- 
velopment. These are very various and are as yet far from being fully 
understood. Bacteria vary very much as to their sensitiveness to the 
soil on which they are planted : some, such as bacillus subtilis, growing 
luxuriantly on a great variety of artificial soils ; some, such as the 
tubercle bacillus, growing only on specially prepared soils ; and others 
again like the leprosy bacillus, the comma-bacillus generally present in 
the mouth, etc., not growing at all on any of the artificial soils which 
have as yet been tried. It is, therefore, impossible to do more here than 
indicate some of the chief points ; a detailed description of the best 
materials and methods of cultivation being given later. 

Bacteria require for their growth, water, carbon, oxygen, nitrogen, 
and various inorganic substances. 

A large amount of water is necessary for the growth of bacteria. If 
the material employed for cultivation is too concentrated, bacteria grow 
with difficulty or not at all. This fact is largely taken advantage of 
in manufactures, as, for instance, in the preservation of fruits by sugar. 
If the material is quite dry, no microorganisms will grow on it. When 
there is a little moisture present, moulds may appear, but it is only w T hen 



80 CHEYNE, BACTERIOLOGY. 

the amount of water is considerable, at least over fifty per cent., that 
bacteria appear. On the other hand, there must not be too much water, 
■ — in other words, the nutritive material must not be too dilute. Many 
bacteria, more especially the bacteria of putrefaction, grow readily 
enough even when the amount of nutriment in the water is very small, 
but this is not the case with all bacteria. Thus Koch has found with 
regard to the bacillus of cholera, that if the ordinary meat infusion 
used for cultivating these organisms (made by infusing one pound of 
meat in a litre of water) be diluted from five to ten times, it becomes 
unsuitable for their growth. Somewhere about eighty per cent, of water 
should probably be present in a good cultivating medium. 

As the bacteria, owing to the absence of chlorophyll, cannot break 
up carbonic acid, they must get their carbon from various organic com- 
pounds. The best of these is sugar, and next to it come, according to 
Nageli, mannite, glycerine, tartrates, etc. As a rule, however, it is the 
more complex substances which contain nitrogen also, such as peptone, 
which are utilized by the plants as the source of their carbon. 

The nitrogen is generally obtained from the albuminates, which, how- 
ever, must be peptonized before they can be taken up as food. Many 
bacteria growing in neutral or alkaline materials do this for themselves 
by the production of a peptonizing ferment. The nitrogen may also be 
obtained from the amides or amines such as acetamid, methylamin, 
leucin, urea, etc., also from salts of ammonium, such as the tartrate, 
lactate, etc. 

Oxygen is necessary for the respiration of the bacteria, carbonic acid 
being given off during growth. Most bacteria take up the free oxygen 
from the atmosphere ; a few, however, seem to prefer to take it from the 
substances in which they are growing. Hence the bacteria were divided 
by Pasteur into two groups ; the aerobic organisms which take up free 
oxygen, and the anaerobic or those which can do without it. Pasteur 
thought that oxygen was not only unnecessary but even hurtful to the 
anaerobic bacteria, but this view is doubtful ; at any rate, the organisms 
to which oxygen is hurtful are fewer in number than Pasteur at first 
thought, and probably even these require a little free oxygen to start 
their growth. The best example of a true anaerobic organism is the 
bacillus of malignant oedema (vibrion septique, Pasteur), which will not 
develop in the presence of oxygen, but grows readily enough if it is absent. 
Gaff ky was able to cultivate it in the interior of jx)tatoes. Many aerobic 
organisms grow very well without air under suitable conditions. In 
order to cultivate either class of organisms without air, they must be 
placed in a material which can undergo fermentation. Under these cir- 
cumstances, according to Pasteur, fermentation goes on more actively 
than when air is admitted. Many aerobic organisms, however, act quite 
as powerfully, or even more so, in the presence of oxygen as without it. 



81 

If the cultivating material is not a fermentiscible one, then air is re- 
quired for the growth of the aerobic organisms. 

The bacteria require only small quantities of mineral substances. 
According to Nageli, the following are necessary : sulphur (in the form 
of sulphates), phosphorus (as phosphates), potash, which may be replaced 
by csesium or rubidium, but not by sodium ; and calcium or magnesium, 
which may also be replaced by barium or strontium. Pasteur, in his 
work on spontaneous generation, demolished the contention of his op- 
ponents that the bacteria originated from the albuminoid materials 
present in the cultivating liquids by showing that these materials were 
not necessary for the development of bacteria and fungi, but could be 
replaced by various salts. The fluid which he employed had the fol- 
lowing composition : 



Distilled water 
Sugar candy 
Tartrate of ammonia 
Ashes of yeast 



100 grammes. 
10 
2 to 5" 
4 



Cohn modified this solution chiefly on account of the difficulty of cal- 
cining the yeast, and proposed the following : 

Acid phosphate of potash 
Tribasic phosphate of lime 
Sulphate of magnesia . 
Tartrate of ammonia . 
Distilled water . 

Nageli proposes the following mixture, founded on an analysis of 
bacteria : 



. 0.1 


gramme 


. 0.1 


a 


. 0.1 


a 


. 1.0 


" 


. 100.0 


c. cm. 



Basic phosphate of potash 
Sulphate of magnesia 
Sulphate of potash 
Chloride of calcium 
Tartrate of ammonia 
Water 



0.1035 gramme. 
0.016 
0.013 
0.0055 
1.0 
100.0 c. cm. 



These solutions are not, however, suitable for general use, for though 
some bacteria grow well in them, a great many, more especially the 
pathogenic ones, require a more complex soil, and in the case of some a 
proper soil has still to be discovered. An immense amount of work yet 
remains to be done on this subject. With regard to these mineral sub- 
stances, it should be remembered that where meat is employed for making 
the cultivating material it is unnecessary to add any salts, as they are 
already present in sufficient quantity in the meat. 1 



1 Raulin (Comptes Rendus, t. 56, p. 229) has made out some very interesting facts with regard to the 
quantity and kind of mineral substances required by asjiergillus niger. 
NO. CLXXXIII. — JULY, 1886. 6 



82 

Apart from the constitution of the cultivating material, many other 
conditions come into play in the way of favoring or hindering develop- 
ment. Thus, the reaction of the cultivating medium is in many cases of 
great importance. Most bacteria grow best in a neutral or slightly alka- 
line medium. To many even slight acidity of the medium is injurious, 
to some the reaction is more or less indifferent. Bacillus subtilis, bacil- 
lus anthracis, the cholera bacillus, and others, do not grow in meat jelly 
if it is not neutralized, or if any growth occurs it is very slight. Although 
this is the case with regard to those bacilli growing in meat jelly, all 
acids do not apparently prevent their growth, for under certain condi- 
tions they flourish well on the surface of boiled potatoes, which is also 
acid. To micrococci the reaction of the medium does not much matter, 
they grow well in slightly acid media. A few organisms even grow best 
in an acid medium, such as the bacillus of blue milk, the bacterium acetii, 
etc. Although it is the reaction, in general, which is usually spoken of as 
injurious or favorable to growth, it is a question whether this is the exact - 
truth, and whether it is not rather the presence or absence of particular 
acids and alkalies which is the important point. That this may be so, is 
shown by the examples mentioned above of the cholera bacillus, etc., 
growing on the acid potato, but not in the acid nutrient jelly. 

Another very important condition for growth is the temperature. 
The range of temperature in which bacteria will grow varies very much 
according to the species, but may be stated generally as from 5° C. to 
50° C. For the majority of bacteria the range is less, the most general 
range being from 16° C. to 45° C. Some of the pathogenic bacteria 
will only grow at a temperature approaching that of the human body ; 
thus, the range of the tubercle bacillus is about from 30° C. to 42 D C. 
Bacterium termo and bacillus subtilis can grow at 5° C. Van Tieghem 
describes a bacillus which grows in neutral solutions at 74° C. While 
there is thus a considerable range of temperature within which bacteria 
can grow, there is, however, a degree of heat which is the best for 
growth, and probably this best temperature differs considerably in dif- 
ferent species and, to some extent, according to the medium in which 
they are growing. Thus, while the tubercle bacillus can grow between 
30° C. and 42° C, it grows best at 37° C. Finckler's comma-bacillus, 
when cultivated on potatoes, grows better at 18° C. than at 37°. The 
cholera bacillus, on the other hand, although it grows in neutral jelly at 
20° C, grows on potatoes only at a higher temperature. With regard to 
temperature, it is also important that it should be constant ; this is more 
especially the case with those which require the higher temperatures for 
their development. 

Experiments have been made on the effect of light on the growth 
and movement of the bacteria, but without yielding any definite results. 
The only two facts worth mentioning are a doubtful one by Engelmann 



CHEYNE, BACTERIOLOGY. 83 

with regard to an organism which he reckons among the bacteria, the 
movement of which was dependent on light, more especially on the 
ultra-red rays of the spectrum, and an observation by Zopf that in 
cultivations of beggiatoa roseo-persicina, the deposit of bacteria was 
greater on the side of the vessel turned toward the light than elsewhere. 

It is stated by Horvath and others that violent movements of the 
cultivating fluid interfere with the growth of bacteria, while a steady 
flow does no harm. 

Pressure exerts a certain influence on the growth of bacteria, and 
when very high may even kill them. Thus Paul Bert found that after 
meat was subjected for three days to a pressure of sixteen atmos- 
pheres and then the j)ressure restored to the normal, with precautions 
against the entrance of fresh germs, putrefaction did not occur, showing 
that the putrefactive bacteria had been killed by the high pressure. 
From a large number of experiments Bert found that a pressure of 
twenty-one atmospheres is sufficient to kill the organisms which cause 
putrefaction. It is probable that it is the oxygen which is the active 
destructive agent. To kill the bacterium lactis in milk, it was necessary 
to employ oxygen at a pressure of about twenty-five atmospheres, and 
to have only a thin layer of fluid. 

Electricity also affects the growth of bacteria. Cohn and Mendelsohn 
obtained the following results with regard to the effects of the constant 
current on bacteria growing in mineral cultivating liquids. A battery 
of two elements rendered the fluid unsuitable for growth in twenty- 
four hours, more especially that at the positive pole, the fluid at that 
pole becoming strongly acid, that at the negative becoming alkaline 
(from formation of ammonia). The bacteria themselves, however, were 
not killed, but developed readily when introduced into fresh cultivating 
fluid. A battery of five cells killed the bacteria completely in twenty- 
four hours. They explain this as the result of the electrolysis. The 
induction current had no effect. Somewhat similar results were obtained 
in the case of micrococcus prodigiosus growing on the surface of boiled 
potatoes. The fluids of the potato become acid at the positive pole and 
alkaline at the negative. With weak currents there is a broad colorless 
zone in the neighborhood of the positive pole, and a much narrower one 
around the negative pole, while the rest of the potato is covered with 
the red growth. The stronger the current the broader is the zone at 
both electrodes in which the micrococci cannot develop; with very 
strong currents the micrococci are killed. 

Various other unknown conditions, meteorological and otherwise, no 
doubt influence the growth of bacteria in the outer world. A striking 
instance of this was mentioned by Koch at the second cholera conference 
held at Berlin in May, 1885. 1 "The town of Bombay has for some 

1 Berliner klin. Wochenschrift, No. 376, 1885. 



84 CHEYNE, BACTERIOLOGY. 

years been provided with water from a neighboring island. A valley 
has been dammed and thereby an artificial lake, the Vehar lake, has 
been formed. In this lake, which is filled with the water from the trop- 
ical summer rains, the water every spring, some months before the com- 
mencement of the monsoon, becomes suddenly turbid from the develop- 
ment of numerous microorganisms. According to the drawings, these 
seem to be a form of bacteria. Immediately after the commencement 
of the monsoon, and yet before the rain has had any important influence 
on the water, this bacterial vegetation disappears suddenly and the water 
becomes clear. One could not say in this case that the rain had caused 
great dilution, or in any other way had an influence on the water in the 
Vehar lake. These microorganisms have thus their definite periods of 
vegetation without our being able to say with certainty why this 
occurs." 

The length of life and retention of vitality of bacteria under adverse 
circumstances vary much in different species of bacteria, and in the case 
of spore-bearing bacteria they also depend on whether the organisms 
are in the spore stage or in the adult condition. Much depends on the 
soil, on the temperature at which they are kept, and on the presence or 
absence of oxygen. In nutrient jelly kept at 16° C. or 17° C, the life 
of micrococci varies much, from four to six weeks to several months, and 
similar variations are observed in regard to bacilli. The cholera bacil- 
lus, for instance, remains alive for six to eight weeks in tubes containing 
about 10 c. cm. of the nutrient jelly; on agar- agar jelly they have been 
found to retain their vitality for 170 days, and even longer. In fluids, 
micrococci live a much shorter time, especially if they are kept at the 
body temperature freely exposed to air and in only a thin layer of fluid. 
When working with micrococci from aseptic wounds cultivated in a 
small quantity of unneutralized cucumber infusion at the temperature 
of the body, I found that they died in from two to four days. Whether 
this was due to exhaustion of the pabulum, to formation of products 
injurious to them or to the temperature and oxygen, I cannot say. Nor 
have I investigated whether this holds good with regard to other micro- 
cocci or to the same micrococci grown in fluids of different composition. 
Apart from what may be looked on as the natural death of these organ- 
isms as the result of exhaustion of food, of destruction, by their own 
products, of the effects of oxygen, etc., their growth and vitality may be 
interfered with in various ways, such as by dryness, by temperature, and 
by the action of various chemical substances. The discussion of these 
matters will, however, be more conveniently dealt with when we come 
to consider the subject of disinfection. 

A much debated question with regard to bacteria is the existence of 
distinct species and varieties. Some writers, such as Billroth, Warming, 
and others, have denied the existence of distinct species, and consider 



CHEYNE, BACTERIOLOGY. 85 

that there is only one species of bacteria from which all the various 
forms are derived, the organism assuming different forms and functions 
according to the circumstances in which it is placed. These statements, 
however, rest on two errors; the first being that impure cultivations 
containing a variety of bacteria have been worked with, and the second, 
that too much stress has been laid on the microscopic characters. Of 
course, if one starts with the view that species of bacteria do not exist, 
and under this idea experiments with any admixture of bacteria which 
comes to hand, one will very soon come to believe in its accuracy ; for, 
if inoculation be performed into different soils from the original mixture, 
one will obtain in the one micrococci, in the other bacilli, and so on ac- 
cording as the soil is more suitable for the growth of one or other form 
of microorganism. And it may be that, assuming the original culture 
to be pure, the observer concludes that he sees a transformation of one 
form into another according to variations in the nature of the soil. The 
other error is equally grave. With such minute objects as bacteria, it 
is hardly to be expected that the microscope will show sufficient differ- 
ences in many cases to enable the observer to say that he has different 
forms before him. It is necessary, in judging of the existence of species, 
to have pure cultivations, and to take into consideration other character- 
istics besides mere form. This is the more important, as the same kind 
of bacterium often differs greatly in form according to the conditions 
under which it is grown. Thus, take the cholera bacillus for example, 
when grown in meat infusion at the temperature of the body, it is at 
first hardly, if at all, curved. When grown in neutral jelly at 20° C, 
almost all the cells are slightly curved ; but in many the curve is not 
very marked. When the jelly is slightly acid the growth is slower, and 
all the organisms are markedly curved. When ten per cent, of alcohol 
is added to the neutral jelly, almost all the organisms have the spirillar 
form. How would it be possible, by means of the microscope, to say 
that these were all forms of the same organism ? But, by taking into 
account their other characteristics, such as the mode in which they grow 
in different media, a decision can readily be arrived at. Inoculate neu- 
tral jelly from the meat infusion, from the neutral jelly, from the acid 
jelly, or from the mixture of alcohol and jelly, and the resulting growth 
will be similar in all cases, showing that the same organism is being 
dealt with. By looking at the subject in this way, and taking all the 
characteristics into account, there can be no doubt that many definite 
species or varieties of bacteria do exist having definite characteristics, 
the sum of which enables them to be distinguished one from another. 
Wherever these characteristics are proved not to be accidental, but con- 
stant, one must assume that, however nearly allied, the bacteria are 
different, the only question being whether they should be looked on as 
distinct species or only as varieties of the same species. Wherever an 



86 CHEYNE, BACTERIOLOGY. 

organism is found differing in some point or points from any other known 
form, it is, I think, always safer to look on it provisionally as a new 
species. It may subsequently turn out that it includes a number of 
species, or that, on the contrary, it is a form of some species already 
known. On the other hand, to assume at once because the differences 
between two evidently allied forms are slight that therefore they are 
identical is not philosophical, and can only, as, indeed, it has already 
done, lead to endless confusion. 

Another point to which reference must be made is that of the con- 
stancy of species. Many observers, paying attention only to the micro- 
scopical appearances, have held that one species could be readily trans- 
formed into another by altering the conditions under which it grows. 
But when these statements have been put to the test they have been 
found wanting, and there is no instance known, although numerous 
efforts have been made to obtain this evidence, of an organism possessing 
certain definite characteristics being transformed into another presenting 
other characters. Here, again, the change in form assumed by various 
bacteria under different circumstances has misled observers into believing 
that with the change in form they have changed their characters. That 
this is not so is shown by the example of the cholera bacillus mentioned 
in the previous paragraph. However probable it is that in the course of 
ages bacteria may have undergone slow change, there is no evidence 
nor probability that this occurs more rapidly in them than in other 
living things, and therefore the evolution theory is no bar to the accept- 
ance of the existence of permanent species and varieties among the 
bacteria as among other plants and animals. 

The distribution of bacteria in nature is very wide — indeed, they may 
be said to occur everywhere. They are probably present in smaller 
numbers in the air than elsewhere. 

That they may be present in air has been recognized from the very 
early experiments on bacteria with reference to the question of spon- 
taneous generation, when Spallanzani hermetically sealed his flasks to 
prevent their entrance, when Schulze interposed sulphuric acid and 
caustic potash between the air and the putrescible material, when 
Schwann heated the air which had access to the flasks, and Schroder and 
Dusch filtered it through cotton-wool. Pasteur was the first, however, 
who went into the matter more thoroughly, and showed that the air in 
different places and at different times contained varying numbers of 
bacteria. Numerous attempts have since been made to estimate the 
numbers of bacteria in a given quantity of air by drawing the air over 
plates smeared with some glutinous substance, such as glycerine, or 
by catching the particles in gun-cotton, etc., and then counting the 
number of spores or bacteria by means of the microscope. This is a 
most inefficient method, as it is impossible, on the one hand, to recognize 



87 

all the spores and bacteria present, and, on the other, of those seen it is 
impossible to say which are alive and which are dead. Miguel has gone 
into the question of the bacteria in air very carefully, both by methods 
similar to those just mentioned, and also by cultivation in fluids by 
aspiration of a given quantity of air through cultivating fluids. He has 
made out some very remarkable results with regard to the number of 
bacteria in the air at different seasons of the year, and at different hours 
of the day. During rain the number of bacteria in the air is small, as 
would naturally be expected, while they increase in number during 
periods of drought, but apparently decrease again if the drought lasts 
longer than a week. In autumn and winter there were much fewer 
bacteria in the air than in spring and summer, but this is apparently 
not always constant, and further facts are required. As regards the 
hourly variations, Miguel has made an extensive investigation, and he 
finds that, independent of rain and other causes which alter the number 
of bacteria, there are certain fairly constant hourly variations. At noon 
till one o'clock there are but few bacteria present in the air, from one the 
numbers increase till eight in the evening, when they again diminish till 
between one and three in the morning, when increase again occurs. The 
minimum is at noon, the maximum apparently from eight to ten in the 
evening. Miguel ascribes these hourly variations to variations in the 
obliquity of the currents of air. Of late, Miguel has employed the 
gelatine cultivation methods by spreading the nutrient jelly on a thin 
sheet of paper, and fixing it around a revolving drum against which a 
current of air is projected. The germs are thus sown on the prepared 
paper, which is then placed in a suitable place for development. 

In Koch's laboratory, methods of examining air have been devised 
which are more trustworthy than those just described. Koch exposed 
plates, covered with nutrient jelly, to air for a given time, and then cov- 
ered them up and placed them in suitable conditions for the occurrence 
of development. As the medium was solid, each microorganism which 
fell on it developed where it fell, and by-and-by its progeny formed a 
mass, or colony, visible to the naked eye. By counting the number of 
colonies one could estimate approximately the number of microorgan- 
isms which fell on the material, and could further tell the kinds. In 
reality this is only a qualitative test, because the volume of air over the 
plate being constantly changing, no definite result was obtained as to the 
number present in a given quantity of air. Hesse has improved this 
method, and made it not only a qualitative but a fairly accurate quan- 
titative test. Through a tube coated with nutrient jelly a given quan- 
tity of air is drawn at a given rate in the manner to be afterward 
described. The germs in the air are deposited on the jelly and grow 
there. After a sufficient quantity of air has been drawn through the 
tube it is closed and placed at a suitable temperature for development. 



88 CHEYNE, BACTERIOLOGY. 

The number of colonies which appear are counted, and the kinds of bac- 
teria present are ascertained. By proceeding in this way Hesse has 
made out some very interesting facts, of which a few may be mentioned. 
Experiments were made in the open air, in Berlin, in winter, and showed 
that during a drizzling rain 12 germs (bacteria or fungi) were present 
per litre of air ; during snow, 0.26 per litre ; when dry, 0.5 per litre ; on 
the top of a tower, 0.8 per litre ; in the court beneath, 2.2 per litre. In 
Hesse's sitting-room, the following results w r ere obtained : during the day, 
7 germs per litre ; while the room was being dusted, about 20 per litre ; 
immediately after supper, 6 per litre ; and at midnight after the room 
had been empty for some hours, only 1 fungus was found in 5 litres. 
Very interesting results were obtained in hospital wards : in one ward, 
containing 17 beds, which communicated with two other wards each of 
which contained 11 beds, 3 germs per litre were found when the ward 
was still ; in one with 14 beds, there were also 3 per litre ; and in another 
with the same number of beds, there was 1 per litre. In the surgical 
wards (18 beds), just after sweeping, there were 12 per litre. The air in 
a schoolroom was tested (a ) before the class assembled, when 2 germs 
per litre were found ; (b) while the class was going on, 16 per litre ; and 
(c) while the class was being dismissed, 35 per litre. In rooms not kept 
clean or quiet there were many more organisms : thus, in the stall where 
the animals for experiment were kept, from 40 to 65 germs were present 
per litre, while the animals were being fed, and the much larger propor- 
tion of bacteria to fungi was very noticeable. In the rag sorting room 
of a paper-factory the germs present in a litre of air were so numerous 
that a precise estimate could not be made. Hesse further found that 
the air passing through thickly packed moist earth or dung did not carry 
bacteria with it, and this was also the result obtained by forcing air 
through water containing numerous putrefactive bacteria. Hesse made 
the interesting observation that the bacteria in air were attached for the 
most part to particles of dust, while the spores of fungi were not. This 
was shown by the fact that, if the air were drawn through porous sand- 
stone, no bacteria developed while fungi did ; the spores of fungi being 
larger than those of bacilli, the latter must have been attached to some 
gross particles. With regard to all these methods of examining air by 
cultivation, it must be remembered that the result is only approximately 
accurate, for germs may be present which will not grow on the nutri- 
ent jelly at the temperature at which it is kept- — as e. g., the tubercle 
bacillus ; or, on the other hand, germs may grow, but grow so slowly that 
neighboring colonies may cover them, or may liquefy the jelly before 
their colonies are apparent, or, again, germs capable of growing in the 
material may lie on the dry surface without taking root. Other modified 
methods of examining air will be described afterward. 

As air in almost every situation contains microorganisms or their 



CHEYNE, BACTERIOLOGY. 89 

spores, it follows that dust must likewise contain them and, of course, in 
very much larger quantity. This can be proved by a very simple ex- 
periment. Pour out some liquefied nutrient jelly on a sterilized glass 
plate and allow it to solidify in a moist chamber protected from dust. 
Then with a sterilized penknife pick up a minute portion of dust and 
scatter it over the surface of the jelly. In a few days a large number 
of colonies, more especially of fungi, will be seen on the surface, corre- 
sponding to the particles of dust which fell on it. The number and 
kinds present will depend on the age and the dryness of the dust. The 
drier and older the dust, the fewer micrococci and adult bacilli remain 
alive in it, till ultimately only the spores of bacilli and fungi, more 
especially of the latter, remain capable of development. 

As dust is present everywhere, so these spores of bacteria and fungi 
are also present everywhere, on all surrounding objects and more espe- 
cially on the surfaces of our bodies. The last is a most important fact 
to remember in connection with the treatment of wounds. On the skin, 
moreover, they are not only present in the spore stage, but, being in the 
presence of both heat and moisture, they also exist in the growing form. 
On the skin the micrococci are apparently much more numerous than 
the bacilli. This probably depends to a great extent on the acidity of 
the sweat being more favorable to the growth of micrococci than of 
many forms of bacilli. Their presence in the growing form rather than 
in the spore stage is very important, as rendering disinfection of the skin 
by means of carbolic acid more efficacious than if spores only were 
present. 

Bacteria form a very important part of the constituents of the super- 
ficial layers of the soil, being concerned, as we shall see presently, in 
breaking up the complex organic substances of which soil is largely 
composed and more especially in carrying on the process of nitrification. 
All sorts of bacteria may be present in the soil, but there are certain 
forms of bacilli which are always found in large numbers and which 
are apparently constantly present. Koch found in his early investiga- 
tions that the number of microorganisms in the earth diminished the 
deeper he went, till at the depth of scarcely a metre the earth was almost 
free from microorganisms. These investigations were made in winter 
and require to be repeated. 

In water also bacteria are always present, often in considerable 
numbers, varying, of course, according to the amount of pabulum (or- 
ganic matter) present, the stagnation or rapid flow, etc. Koch's method 
of testing w T ater is to mix a certain quantity of the water (generally one 
c. cm.) with ten c. cm. of liquefied nutrient jelly ; pour the mixture out 
on a sterilized plate of glass, allow it to solidify, and then place it in a 
moist chamber, protected from dust and kept at a temperature suit- 
able for development. The results obtained by this method of testing 



90 CHEYNE, BACTERIOLOGY. 

water are now added to the reports of the chemical examination of water 
issued from the Sanitary Institute, in Berlin, and this examination will, 
no doubt, soon be everywhere recognized as an essential part of water 
analysis. The following facts taken from Dr. Wolffhiigel's report on 
the Berlin water will give a general idea of the ordinary distribution of 
bacteria in water. 1 The results were obtained between July, 1884, and 
March, 1885. In river water, before filtration, the highest average 
number of bacteria during one month occurred in October when there 
were 3251 organisms per c. cm. of water. The smallest number was 
during November, when there were 466 per c. cm. After nitration 
through sand the numbers in October per c. cm. of water were 21, and 
in November 27. In other water-works, where the water was taken from 
a lake, the highest number in the unfiltered water was 890 per c. cm., 
in March, and the lowest 167, in September; after nitration through 
sand these numbers fell to 45 and 38 respectively. In the Berlin tap 
water the number of bacteria varied from 12 per c. cm. in Wilhelm- 
strasse, in November, to as high as 409, in July, in Friedrichstrasse, the 
average for the nine months in five different streets in Berlin being 78 
per c. cm. 

Bacteria are, of course, especially numerous in all putrefying materials, 
for, as we shall see presently, the decomposition of organic substances is 
the result of the growth of bacteria. In sewage, Dr. Warden has found 
as many as 38,000,000 per c. cm. 

We have seen that bacteria are present everywhere on the outer sur- 
face of the living body. They are also present on several mucous surfaces, 
more especially in the nose, mouth, and intestinal canal. In the mouth 
there is a great variety of different kinds of bacteria present ; in the 
intestine they are chiefly bacilli, of which at least five different kinds are, 
according to Bienstock/ 2 constantly present in the healthy adult, two of 
which, at any rate, are very important agents in digestion, one decom- 
posing albumen and producing among other substances phenol and indol ; 
the other decomposing hydrocarbons and producing alcohol and lactic 
acid. Escherich 3 found that the meconium of children dying during 
birth did not contain any bacteria, but they could be found in from four 
to twelve hours after birth in feces taken from the rectum. The earliest 
forms found are mostly cocci and torulse, but bacilli very rapidly appear, 
and in twenty-four hours the bacteria are as numerous as in the intestines 
of adults, and of many different kinds. Most of these diverse forms 
disappear in from eight to ten days, when the following condition is 
found. In the feces of infants which have no other food than the 
mother's milk, there is one form of small bacillus present in such 

1 Arbeiten aus dem Kais. Gesundheitsamte, vol. i., 1885. 

2 Ueber die Bacterien der Faeces Zeitschrift f. klin. Med., vol. viii. 

3 Fortschritte der Medicin, Nos. 1G and 17, 1885. 



CHEYNE, BACTERIOLOGY. 91 

enormous numbers that one might think that the intestinal contents 
contained a pure cultivation of this organism. They can slowly coagu- 
late milk and act on the grape sugar. Another form, which is much 
less numerous, closely resembles the bacterium lactis and produces similar 
effects on milk. Other forms of bacilli and micrococci are present in 
small numbers in the feces of infants. Bacteria do not occur in the 
healthy stomach, probably on account of the acidity, but in diseased 
conditions, such as cancerous stricture of the pylorus, where the secretions 
are no longer normal, various forms, more especially sarcinse, may be 
found. 

A most interesting and important question is whether bacteria are 
normally present in the tissues and juices of the healthy living body. 1 
This has now been shown not to be the case, or at least, if they do pene- 
trate into the body, they are rapidly destroyed. Indeed, it seems as if 
they could not penetrate even into the healthy cutaneous or mucous 
glands, though when these are unhealthy they very soon enter. Of 
course, I speak of non-pathogenic forms. 

As to vegetables, Van der Broeck, Pasteur, and Roberts, showed the 
absence of organisms in the fresh grape. The mode in which Roberts 
did this w r as as follows : pipettes were constructed, the upper ends of 
which were plugged with cotton-wool, while the lower were drawn out 
to a point and sealed. These were sterilized, some of them containing 
sterilized water and some not. One spot on a grape was heated in the 
flame of a spirit lamp to destroy adhering germs and then the point of 
the pipette was forced through the skin at this place, broken off in the 
interior of the grape and a little of the juice collected in the pipette. 
The orifice was again sealed, and it was found that no organisms grew 
either in the tubes containing pure grape juice or in those containing a 
mixture of grape juice and water. By proceeding in a similar manner, 
Roberts succeeded also with turnips, potatoes, oranges, and tomatoes. 
Of course, the attempts were not always successful, but in all experiments 
of this kind a certain margin must always be allowed for unavoidable 
errors. 

In the case of animal tissues there is now a large amount of evidence 
to show that bacteria are not normally present in the tissues in health — 
at any rate, that they are neither present in any numbers nor for any 
length of time. That they may now and then gain access to the healthy 
blood through scratches, etc., is extremely probable, but they very 
rapidly die and are excreted by the kidneys. In December, 1877, I 
commenced a series of experiments on this subject which definitely 
proved that bacteria were not normally constantly present in the blood 

1 Details of the researches on this subject will be found in my Antiseptic Surgery. London : 
Smith, Elder & Co., 1882. Chapter II , and also pp. 195 and 248. 



92 CHEYNE, BACTERIOLOGY. 

or organs, as had been assumed by previous investigators, notably by 
Billroth and Tiegel. My plan was to transfer portions of the tissues 
and organs of healthy rabbits, with various precautions, to vessels con- 
taining sterilized infusions, in which bacteria would grow readily. After 
plugging the vessels with cotton-wool they were placed in an incubator 
kept at the temperature of the body. The result was that in a number 
of instances no development whatever occurred, showing that at least 
none of the ordinary microorganisms were present in the tissues. In 
two cases development did occur, twice in connection with the kidney, 
and once in connection with the liver. The explanation of this may 
either be error in manipulation or the presence of microorganisms in 
the tissue. As large portions of the organs were used, it would not be 
surprising if an organism had been present in the circulating blood and 
had not yet been destroyed. Similar experiments have been performed 
by Meissner and others. Meissner was able to preserve the internal 
organs of cats and rabbits in contact with boiled water and pure air for 
three years without any development of microorganisms. 

A number of observers have also shown that microorganisms are not 
present in the healthy blood, nor in such secretions as milk and urine 
when freshly drawn from the body, the latter fact proving, also, that 
bacteria cannot penetrate along small mucous canals when the surfaces 
are healthy and in apposition. 

It is not, however, necessary nowadays to detail the elaborate experi- 
ments which have been performed on this subject, for all who work much 
at bacteriology constantly attempt cultivations in new investigations 
from blood and tissues wuth negative results. For instance, in the ex- 
periments on the cultivation of the organism of tubercle, numerous nega- 
tive results have been obtained. Thus, kill a tuberculous animal and 
make cultivations with its blood or portions of its organs on nutrient 
jelly, or in fluids kept at the ordinary temperature of the air. The result 
will be negative, unless in the rare cases of mixed infection, where mi- 
crococci are present in the blood, for the soil and temperature in this 
case are unfavorable to the growth of the tubercle bacillus. But the 
conditions being favorable for the growth of ordinary bacteria, the nega- 
tive result shows that they were not present even in this diseased animal. 
But it is unnecessary to multiply instances of this kind, for if bacteria 
were normally present in the blood and tissues our present methods of 
examination and cultivation from the living or dead body would prove 
quite insufficient, and would have to be made much more complicated. 

In discussing the origin of the bacteria found in fermenting materials 
and in disease, it is not necessary at the present day to do more than 
allude to the old theories of spontaneous generation, now completely ex- 
ploded. This question, which has done much good in attracting attention 



DONALDSON, KECUERENT LARYNGEAL NERVE. 93 

to these organisms and in leading to their study, and the introduction of 
improved methods of research, has been completely set at rest by the 
experiments of Pasteur, Tyndall, and others, and by the accumulated 
experiences of all recent workers in the field of bacteriology. 1 



THE FUNCTION OF THE RECUEEENT LAEYNGEAL NERVE. 2 

FROM EXPERIMENTAL STUDIES IN THE BIOLOGICAL LABORATORY OF 
THE JOHNS HOPKINS UNIVERSITY. 

By F. Donaldson, Jr., B.A., M.D., 

CHIEF OF CLINIC FOR THROAT AND CHEST, UNIVERSITY OF MARYLAND, AND LATE SCHOLAR IN BIOLOGY, 
JOHNS HOPKINS UNIVERSITY. 

The mode of action of the recurrent laryngeal nerve, supplying as it 
does muscles so important in their use, both phonatory and respiratory, 
and yet so opposed in their action, is at present a much mooted point. 
That this nerve supplies all the intrinsic muscles of the larynx with the 
exception of the crico-thyroid, and that it is chiefly a motor nerve, are well- 
known facts. It is a j^hysiological fact, also, that the internal thyro- 
arytenoids, the lateral crico-arytenoids, and the transverse arytenoid, are 
the adductor (the phonatory) muscles of the larynx, and that the pos- 
terior crico-arytenoids are the abductor (the respiratory) muscles of that 
organ. As we have said, all these muscles receive their nerve supply from 
the recurrent laryngeal. This nerve, then, must contain two sets of 
fibres, which innervate muscles of separate and distinct functions. How, 
and under what circumstances, does the constrictor or respiratory func- 
tion of this nerve assert itself? How are these functions to be differ- 
entiated ? Whence do the two distinct sets of impulses come ? Is the 
origin of the nerve filaments, which compose the recurrent laryngeal 
nerve, as distinct as their function. (Hooper.) 

This important question has, up to the present time, been unanswered, 
and we know of no experiments directly on this point until Dr. F. H. 
Hooper, of Boston, in 1885, published an important and interesting 
paper, entitled "The Respiratory Function of the Human Larynx, from 
Experimental Studies." In this article he considers the question stated 
above, and also whether (as the clinicians assert) the abductor fibres of 
the recurrent nerve are more vulnerable than those of the adductor. It 
was this paper which immediately attracted the writer's attention to this 
subject, and led him to undertake the experiments given below, particu- 

1 For a full discussion of the history of this subject, and of the evidence for and against it, see my 
Antiseptic Surgery, pp. 145-204. 

2 Admission thesis to the American Laryngological Association, May, 18S6 



94 DONALDSON, RECURRENT LARYNGEAL NERVE. 

larly as Dr. Hooper had said, " positive as were the results of this series 
of experiments, we lay no stress upon them. If they are of any worth, it 
would be by suggesting to others some better method than was here 
employed, for all our attempts to verify the observations have failed." 

As my purpose then was, if possible, to verify and expand Dr. Hooper's 
experiments, I am compelled, in order to make myself intelligible, to go 
over somewhat the same ground in the elaboration of this paper. 

Speaking generally, nervous impulses for the larynx start in the 
brain, the medulla, and the cord. That there is a motor centre for the 
larynx is, to say the least, doubtful ; and Delavan's 1 conclusions from the 
two cases cited by him, viz., " that this centre is in the course of the third 
branch of the middle cervical artery, that it is toward the proximal 
end of this vessel, and that it is in the vicinity of the convolution of 
Broca," are hardly justifiable in view of our scant knowledge of the sub- 
ject, physiological and clinical. Nerve impulses are transmitted to the 
larynx through the pneumogastric, the spinal accessory, and their anas- 
tomotic branches. The pneumogastric is connected, first, with the inter- 
nal branch (which contains the medullary fibres) of the spinal accessory ; 
second, with the facial nerve by the auricular branch ; third, with the 
# glossopharyngeal (an inconstant branch) ; fourth, with the hypoglossal ; 
fifth, with the first and second cervical nerves; sixth, with the sympa- 
thetic system. 

The manifold nervous impulses which may come through all these 
sources are carried to the larynx, then, by the superior and inferior 
laryngeal nerves, the anatomy and distribution of which need not be 
given here. 

The part played by all these nerves in the innervation of the larynx 
is greatly in doubt. 

The vagus and spinal accessory, however, are the nerves which im- 
mediately preside over the respiratory and phonatory functions of the 
larynx. The spinal accessory would seem to be chiefly a motor nerve 
(Bischoff, 2 Morganti, 3 Longet, 4 Bernard 5 ). 

Bernard declares that the spinal accessory is the motor nerve for 
phonation alone, and that it has nothing to do with the respiratory 
function of the larynx, which, if I understand him right, is the view 
taken by Schech. 6 It is none the less certain, however, that the re- 
current nerve contains sensory as well as motor fibres, for we can 
obtain reflexes from the larynx after section of the superior laryngeal. 
This latter is the afferent nerve supplying the mucous membrane and 
a motor fibre for the crico-thyroid muscle (denied by Navratil 7 ). Some 

1 On the Localization of the Cortical Motor Centre of the Larynx, N. Y. Medical Kecord, p. 178, 1885. 

2 Nervi acces, etc., Heidelberg, 1832. 3 Extract in Schmidt's Jahrb., xlii. p. 280. 
4 Traite de Physiologie, vol. iii. p. 516. 5 Lecons sur la phys., vol. ii. p. 244. 

6 Die Funct. d. Nerven u. Muskeln des Kehlkopfs, Wurzburg, 1873. 

7 Berl. klin. Woch., 1871, p. 394. 



DONALDSON, RECURRENT LARYNGEAL NERVE. 95 

observers hold that it also supplies a branch to the posterior arytenoid. 
The recurrent nerve therefore containing, as it does, both sensory and 
motor fibres, from whatever source they come, supplying all the muscles 
of the larynx except the crico-thyroid (though Tiirck 1 says that it fur- 
nishes fibres to this muscle also), and being essentially the respiratory 
nerve of the larynx, is the nerve with the innervation of which we are 
immediately concerned. How is it, then, that the impulses travelling 
along this nerve, at one instant close and at the next open the glottis ? 
How is it that at one moment the nerve stimulus acts upon one set of 
muscles (the adductors), and at the next upon another and distinct 
set (the abductors). Those most important muscles, the posterior crico- 
arytenoids, receive, says Hooper, an abundant nerve supply, and it is 
more than probable that the nerve filaments in the recurrent are de- 
rived from a greater number of sources than those in the phonatory 
nerves. The experiments given below were undertaken to test Hooper's 
theory of the innervation of the larynx, and as it is original with him, 
I shall give, in his own words, the reasoning on which he founded his 
theory : 

"It is a familiar fact to all, that if anything other than air finds its way 
into the larynx it produces, by reflex action, a sudden closure of the glottis. 
It is equally certain that, under normal conditions, the same contraction of 
the laryngeal muscles may be instantly called forth by direct stimulation of 
one or both of the recurrent nerves. Now, it may with reason be asked, 
How is it that this constricting action of the phonatory muscles is brought 
about if it be true that the nerve fibres animating the dilators of the glottis are 
the stronger and the more numerous ? Why should we not get adduction of 
the vocal bands instead of adduction on irritating the recurrent nerves? 
The phonatory muscles are to the respiratory muscles as five to two, and the 
closure of the glottis has always been ascribed to the superior numerical 
strength of these constrictors. Yet if we compare, bulk for bulk, the mus- 
cular fibres which compose the five muscles of phonation with those of the 
two respiratory muscles, we do not find that they are much, if any, in excess 
of the latter, and we venture to think that there is some other factor con- 
cerned in this phenomenon apart from mere muscular force. It may be 
sought, perhaps, in this important difference between the respiratory and the 
phonatory function of the glottis, namely, that while the respiratory muscles 
are ever on the alert, holding the glottis open during the entire healthy life 
of an individual, in his waking as well as in his sleeping hours, the phona- 
tory muscles, on the other hand, are more dependent upon the consciousness of 
the individual in order to respond to any irritation. To explain : The phonatory 
function of the phonatory muscles could, as far as life is concerned, be dis- 
pensed with. Not so their constricting action with the view of excluding 
the passage of foreign bodies to the lungs. The constrictor muscles of the 
larynx are the sentinels who guard the approach to these vital organs. But 
they cease to act if the animal is in profound narcosis ; they are asleep, so to 
speak, on their watch. A man in the condition known as ' dead drunk,' 
lying, let us suppose, on his back with his mouth open, would offer no 
obstacle to prevent any living insect that chanced his way from crawling in 
and out of his mouth, or meandering around in his larynx a volonte, without 
exciting reflex contraction of its nmscles. The power of ether, chloroform, 
and other anaesthetics to impair the action of these constrictors is too well 

i Klinik d. Krankheiten d. Kehlkopfs, p. 439, Wien, 1866. 



96 DONALDSON, RECURRENT LARYNGEAL NERVE. 

known to need mention. To carry this line of thought a little further, should 
we not expect that, provided we could preserve the organic life of an animal 
while its volition was at the same time completely abolished — should we not 
expect, we ask, under these circumstances, to get a dilatation of the glottis 
on irritating the recurrent nerves instead of a closure, for the posterior crico- 
arytenoid muscles are muscles of organic life ? Indeed we believe we should, 
and we submit the following experiments in support of that belief." 

Dr. Hooper's experiments were performed upon dogs which were 
etherized, the mouth opened and the tongue drawn out so as to expose 
the larynx to view. The recurrent nerves were then exposed, cut, and 
stimulated at will. The results of the experiments apparently confirmed 
the theory given above, viz., that the constrictor functions of the larynx 
are dependent upon consciousness. And the conclusions drawn from 
them may be briefly stated as follows : That stimulation of the recurrent 
laryngeal nerve always produced abduction of the arytenoid on that 
side, provided the animal was deeply under ether ; that on removing 
the anaesthetic, the dilatation produced by stimulation became less and 
less as the animal regained consciousness, until finally contraction of the 
glottis followed; and that the abduction differed in different dogs. 
These effects were noticed when the dogs were under morphine, chloral, 
and chloroform, though not to the same extent as when under ether. In 
other words, he concludes that the tendency of the glottis is to remain 
widely open, and that any given stimulus from the recurrent nerve 
would act upon the abductor muscles alone unless volition came into 
play, when the stimulus would exert the opposite effect and produce 
abbuction. Such being Hooper's theory and his conclusions, I pass to 
my own series of experiments, undertaken to test the following points: 

First. Is it true that the constrictors cease to act during profound 
narcosis, or when consciousness is suspended from any cause ? 

Second. Do we, as Hooper says, always get abduction of the arytenoids 
(dilatation of the glottis) on stimulation of the recurrent nerves, when 
consciousness is suspended ? 

Experiment I. — Medium-sized dog, under small dose of morphia. 
Slight movement of the glottis during quiet breathing. Kecurrents ex- 
posed ; stimulation of the right nerve produced complete adduction of 
that cord, and slight adduction of the opposite one. The same result 
followed stimulation of the left recurrent. The nerves were stimulated 
from time to time for an hour or more, with the same result. The ani- 
mal now began to come from under the narcotic, and it was therefore 
tracheotomized, and ether given, and while there was still considerable 
movement of the glottis upon stimulation of right and left recurrent, I 
thought I noticed a slight abduction on the side stimulated, but in a few 
minutes, when the animal was deeply under the anaesthetic, and all move- 
ment of the larynx had ceased, stimulation of both recurrents separately 
produced a complete closure of the glottis. I am inclined to think, 
therefore, that the first apparent abduction was the result simply of the 
normal movement of the vocal cords in inspiration. In order now to 
do away with any possible movement of the larynx, the animal was 



DONALDSON, RECURRENT LARYNGEAL NERVE. 97 

made completely apnoeic, and the right recurrent nerve cut, on stimu- 
lation marked adduction was observed ; the other nerve was now cut, 
and stimulation again produced adduction. 

Experiment II. — Large dog, deeply under ether and chloroform. 
Stimulation of the right recurrent produced marked adduction. This 
nerve was now cut, and the left nerve stimulated, when marked adduction 
was produced. The right nerve was now traced to its final division, and 
the branches going to the posterior arytenoid, and those going to the 
other muscles, were tied and Cut. Stimulation of the inferior or crico- 
arytenoid branch produced marked abduction, dragging the cartilage 
completely to the side. On the other hand, stimulation of the superior 
branch produced complete closure of the glottis, as was expected. 
Stimulation, however, of the branches simultaneously invariably pro- 
duced adduction. These results were obtained over and over again. 
The dog meanwhile being profoundly anaesthetized, and the nerves being 
thus separate, I thought it would be well to see if I could get any proof 
of the fact, stated by clinicians, that the abductor nerve fibres were 
prone to injury and disease. And though the two nerves were exposed 
and cut for the space of an hour and a half, I could find no difference 
in their action ; they responded equally to stimulation. That all possible 
consciousness might be done away with, the dog was bled to death ; 
stimulation of either recurrent invariably produced adduction. 

Experiment III. —Medium-sized dog, under morphia. Nerve dis- 
sected out to final distribution ; stimulation resulted as in former experi- 
ment. Thinking now that the kind of stimulation might make some 
difference, a crystal of sodium chloride was placed upon the left nerve. 
The cord was alternately abducted and adducted as different fibres of 
the nerve were affected by the salt, though the general result was rather 
one of adduction. The result of pinching the nerve was, generally 
speaking, adduction. 

Experiment IV. — Fair-sized dog, somewhat under morphia, later 
profoundly under ether. Right recurrent stimulated and adduction 
followed. The nerve was cut and adduction again resulted ; there were 
no appreciable movements of the larynx at this time. The left recurrent, 
uncut, was now stimulated and adduction resulted. The latter nerve 
was cut and stimulation invariably gave adduction. Stimulation by 
pinching produced adduction. After the nerve had been somewhat 
injured it was stimulated below the point of injury to see whether one 
or the other fibres might have degenerated more rapidly, but adduction 
again resulted. 

Experiment V. — Fair-sized dog, under ether only. The nerves 
were not stimulated until the animal was profoundly narcotized and all 
movement of the glottis had ceased, when stimulation of either nerve, 
cut and uncut, always produced adduction. The dog was killed and 
after some minutes adduction was produced on stimulation. The strength 
of the current in all these experiments was always considerable, the 
induction coil being at about 10. In this series of five experiments 
under no condition had abduction of either cord been obtained, as Dr. 
Hooper had found. Now Dr. Hooper's results, seen by Dr. Bowditch 
and himself, must have existed, and so I was put to it to account for the 
great diversity in my own results. The experiments up to this point 
had been performed under like conditions, and sources of error excluded 
as far as possible. The next experiment was carried on with the utmost 

NO. CLXXXIII. — JULY, 1886. 7 



98 DONALDSON, RECURRENT LARYNGEAL NERVE. 

care and with unexpected results. In the experiments given above the 
induction coil was at 10, giving always a strong stimulus. 

Experiment VI. — Medium-sized dog, under ether. Professor Martin 
having suggested that possibly the results obtained by Hooper were 
reflex (both Burkhard and Hermann stating that the recurrent had 
sensory as well as motor fibres), the right recurrent was stimulated uncut, 
but with the usual result, adduction. 

Though the animal was deeply narcotized there were still some move- 
ments of the glottis, and to do away with these the dog was accordingly 
made deeply apnoeic. Under this condition it was observed that the 
cords came nearer together than in normal breathing, which is what 
might be expected ; no impulses proceeding in this condition from the 
respiratory centre. The nerve was now stimulated and adduction was 
strongly marked. The right nerve was cut and stimulated, but with 
the same result. That all possible respiratory movements might be 
done away with and consciousness entirely removed, the medulla was 
destroyed and artificial respiration kept up. The right nerve was now 
cut, the induction coil was moved out and the stimulus made very weak 
(more by accident than intent), when, much to our surprise, abduction, 
distinct and prolonged, resulted. The stimulus was gradually increased, 
with the same result, until the coil stopped at 16, when adduction of the 
cord took place. This result was obtained again and again on stimula- 
tion of either nerve. Here then, at last, we had the result obtained 
by Hooper. All consciousness in this case had been suspended. Was 
the abduction, then, as Hooper declares, dependent upon unconscious- 
ness and loss of volition ? Hitherto we had obtained adduction under 
all circumstances, with the animal slightly, deeply, and entirely narco- 
tized, and indeed when dead. Was not this abduction, just obtained, 
dependent upon the strength of the stimulus? Was not the abduction 
due rather to the greater irritability of the abductor muscles which 
caused them to answer to a much slighter stimulus than the adductor 
muscles ? and was not this what we might expect from the vital impor- 
tance of the former pair of muscles? Finally, did the abduction depend 
upon unconsciousness, or would we obtain the same result with volition 
at work ? 

Experiment VII. — Medium-sized dog, under ether only, right recur- 
rent cut, and the animal well though not deeply narcotized; induction coil 
placed at 35 : the stimulus was too weak, however, and no movement was 
visible. At 34 there was slight abduction of the arytenoid, which be- 
came more marked as the stimulus was increased. At 18 the abduction 
was greatest. At 16 the abduction was slight. At 14 the cord vibrated 
between abduction and adduction. At 10 adduction was most marked. 
At this last point slight contact produced a momentary abduction, which 
movement passed into adduction on full contact and stimulation. The 
abductor muscles seemed to lose their power and become exhausted 
upon strong and continued stimulation. The animal by this time had 
become deeply narcotized. In order to see whether volition would alter 
the results, the dog was allowed to come almost completely from under 
the influence of the ansesthetic : reflexes were numerous and marked. 
The coil was placed at 30, and abduction followed, as indeed it did until 
the coil reached 12, when a mixed movement resulted, and at 10 adduc- 
tion followed stimulation. The change in the number at which adduc- 
tion or abduction followed, may be explained by some exhaustion of the 



DONALDSON, EECUKEBNT LARYNGEAL NERVE. 99 

nerve from continued stimulation. Both the recurrents were now cut, 
and thinking that the number of stimuli might make a difference, the 
interruptions were made in turn very slow and very rapid, but with no 
change in the results as given above. The experiment then confirmed the 
results of the previous one, and seemed to show that the abductor muscles 
were much more irritable than the adductors ; and that abduction de- 
pended in no way upon volition, as the same result was obtained whether 
the animal was conscious or unconscious. 

Experiment VIII. — Forty-eight hours previous to operation, about 
one inch of the right recurrent nerve had been excised, with a view to 
finding which, if either, set of fibres contained in it would degenerate 
most rapidly. The dog was deeply etherized and the nerve found. The 
cut end was enveloped in a mass of inflammatory product from which 
it was freed and its end stimulated. With a feeble current the right 
cord, which was completely paralyzed, was strongly abducted, as it was 
indeed upon stimulation with all strengths from weakest to strongest. 
The animal was now allowed to come from under the ether almost 
entirely, with not the slightest change in the results, however ; under 
no circumstances was adduction produced. The left nerve was stimu- 
lated, and with weak current abduction was obtained; with strong, a 
mixed movement. It will be noticed that adduction was never obtained 
from the injured nerve, which would seem entirely to confirm Dr. 
Hooper's conclusion, that the abductor fibres are the less susceptible, 
both to disease and to injury. In this case the adductor fibres seemed to 
have proved the more vulnerable. The dog was now killed, and after a 
short time on stimulation of the right nerve abduction invariably fol- 
lowed, while on the left side adduction only could be obtained with all 
strength of stimulus ; which fact, I think, is explained by supposing that 
the more irritable muscle, the posterior crico-arytenoid, dies more rapidly 
than the less irritable adductors. 

Experiment IX. was confirmatory of previous experiments ; abduc- 
tion depending upon the strength of the stimulus, and abduction and 
adduction obtained whether the animal was narcotized or not. One 
fact was impressed upon me by this experiment, viz., that after constant 
and strong stimulation the abductor muscles became exhausted, and any 
stimulation, therefore, produces adduction. 

Proceeding now to the analysis of these experiments, we find that 
in the first five under no condition was abduction of either or both 
cords obtained, except, of course, where, as in Experiments II. and III., 
the branch of the recurrent going to the posterior arytenoid itself was 
stimulated. Adduction of the arytenoid was obtained, however deeply 
the animal was anaesthetized, in all five experiments. In two cases (Ex- 
periments II. and VI.) where the animal was made thoroughly apnoeic, 
and where for some seconds there was neither glottic nor respiratory 
movement, adduction resulted from stimulation. In two cases after the 
animal was dead, but before death of the nerves or muscles of the 
larynx, stimulation produced closure of the glottis. Under all these 
conditions of unconsciousness and narcotism, then, was adduction pro- 
duced. This result followed, in these experiments, stimulation of the 
cut and uncut nerve ; and followed chemical and mechanical, as well as 



100 DONALDSON, RECURRENT LARYNGEAL NERVE. 

electrical, stimulation. Again, in Experiment II., where the separate 
branches of the recurrent to the individual muscles were dissected out, 
and stimulated equally, neither showed a tendency to more rapid de- 
generation than the other. 

My conclusions then from this first series of experiments are: 1st. 
That the constrictor muscles of the larynx do not cease to act during 
jyrofound narcosis or during suspension of consciousness from any cause; 
or, in other words, that their action is not dependent upon volition, in 
the sense that they lose their power with the loss of volition. 2d. That 
we do not always obtain abduction of the arytenoids when consciousness 
is suspended, as argued by Dr. Hooper. Under what conditions then do 
we get abduction of the cords upon stimulation of the recurrent nerve ? 
Such conditions must exist, for abduction of the cord has been obtained 
by Hooper, who considers that suspension of volition is the one condi- 
tion under which stimulation of the recurrent nerve brings about 
abduction. What the conditions are under which these abductors act 
was, I think, partly discovered in the next series of experiments. In 
them it was found : 1st. That the abduction obtained by Hooper was in 
no way reflex. 2d. That abduction is in no way dependent upon the 
unconsciousness of the animal, as held by him. 3d. That it is with 
weak stimuli only that abduction of the cords takes place, which move- 
ment of abduction gradually passes into one of adduction as the strength 
of the stimulus is increased. 4th. That this result invariably followed, 
whether the animal was slightly, deeply, or thoroughly narcotized ; 
whether the animal was eupnoeic or apnoeic, when the dog had his 
medulla destroyed, and after local death had taken place. 5th. That 
the rate of stimulation did not affect the general result. 6th. That after 
strong and constant stimulation the abductor muscles became worn out 
and ceased to answer to stimuli. 7th. That in apnoea the cords came 
nearer the middle line, the abductors receiving no stimulus in this con- 
dition from the respiratory centre. Here then, I think, we have a sug- 
gestion, at least, as to the innervation of the muscles of the larynx. 
And again we state that volition, consciousness, or unconsciousness in 
no way affect the action of the laryngeal nerves or muscles. In* our 
first series of experiments adduction resulted under all conditions of 
unconsciousness; in our second series abduction, in all conditions of con- 
sciousness or deep narcotism : we may, therefore, cast out volition as a 
factor in our problem. Abduction of the arytenoids Avas found to 
depend simply upon the strength (the rate did not change the result) of 
the stimulus ; dilatation of the glottis followed always weak stimulation 
of the nerve. How is this result then to be explained ? 

It must remain for subsequent investigations to decide whether this 
greater irritability is in the nerve fibres or the muscle fibres, but the fact 
remains that the abductor muscles respond to a much weaker stimulus 



DONALDSON, RECURRENT LARYNGEAL NERVE. 101 

than do the adductors. That their irritability is greater, was proved not 
only by the weaker stimulus to which they responded, but by the fact 
alluded to in Experiment IX. : that, after continued stimulation the 
muscle or nerve fibres of the abductors became exhausted and only ad- 
duction resulted from stimulation of the nerve. Again, in the several 
experiments where the nerves were stimulated after death, only adduc- 
tion after a time could be produced, the more irritable fibres of the 
abductors dying most rapidly. The apparent contradiction in Experi- 
ment VIII., where after section of the right recurrent two days previously, 
abduction only, under all circumstances and with all strengths of stimuli, 
was produced, may, I think, be explained by supposing that for some 
reason the fibres of the adductor muscles had degenerated more rapidly, 
which fact with others leads me to agree entirely with Dr. Hooper's 
statement, that he can find no proof of the assertion of the clinicians, 
that the abductor fibres of the recurrent are prone to disease. This 
clinical fact may be explained, however, by the theory of the greater 
irritability of the abductor muscle or nerve fibres. For in cases of bi- 
lateral paralysis of the cords from an aneurism or tumor, the constant 
pressure exerted by either, upon the nerve, acts as a mechanical stimulus 
to it, and, therefore, the more irritable abductors are the first to show 
the result of this constant stimulation, by their loss of function. Upon 
these facts, then, I would explain the innervation of the larynx some- 
what as follows : Breathing is an involuntary act, though the dia- 
phragm and all the other muscles employed in respiration are voluntary 
muscles ; and though respiration may be modified within very wide 
limits by the will, yet we habitually breathe without the interven- 
tion of the will. The larynx is an essential part of the respiratory 
apparatus and is immediately connected with, and must receive impulses 
from, the respiratory centre in the medulla, and its respiratory function 
is the most important ; for the purpose of preserving life the glottis must 
be kept open, and so we find that the cords, even in normal breathing, 
at each inspiration are pulled slightly away from their apparently normal 
position between extreme abduction and extreme adduction. The fact 
that in deep narcosis the cords are pulled widely apart, w T ould seem to 
show that stronger stimuli than usual are proceeding from the respiratory 
centre to the abductor muscles ; for in all deep narcosis the tendency is 
toward dyspnoea and always in this condition normal respiratory muscles 
are called into greater play. 

The constrictors of the larynx are apparently always in a state of 
partial tonic contraction, and ready for use at any moment. I found 
that in every case where the dog was thoroughly apnoeic that the cords 
came much closer together than in normal breathing ; and this, it seems 
to me, is what we might expect, for in apnoea the respiratory centre 
is at rest; and the respiratory function of the larynx being for the 



102 DONALDSON, KECUERENT LARYNGEAL NERVE. 

moment in abeyance, the protective or constrictor function of that organ 
asserts itself. Again, it is well known that great changes can be brought 
about in the respiratory movements by the will ; while, on the other 
hand, the respiratory centre is the one most frequently affected by nervous 
impulses from various quarters. Is it not fair then to suppose, and I 
think the above experiments support the supposition, that both the respi- 
ratory and constrictor (or protective) functions of the glottis are governed 
by those laws which govern the rest of the respiratory apparatus ? 

It is well known that the pneumogastrics contain two kinds of fibres — 
one accelerating, the other retarding, regulating, or inhibitory. Ordi- 
narily the excitation of the former predominates ; for after division of 
one or both vagi the respiratory rhythm becomes slower. Gentle stimu- 
lation of the central end of the divided vagus produces acceleration of 
the respiration ; if, however, the stimulation is made strong, the action 
of the diaphragm is stopped — it is in a state of relaxation or expiration ; 
this is particularly the case in the fatigue of the nerves; the result being 
due to the fact that the inhibitory fibres do not become so quickly 
exhausted as the accelerators. (Burkhard.) 

The larynx, then, as we have said, being part of the general respira- 
tory apparatus, its inspiratory and expiratory (constricting) functions are 
under the same nerve control as the rest of the organs concerned in inspi- 
ration, and under no circumstances are these functions suspended. 

The action of the constrictor muscles is second only in importance to 
that of the dilator muscles, and we do not think, in view of the results 
obtained above, nor upon general principles, that nature would allow (as 
held by Dr. Hooper) so important a function to be susj^ended ; and, 
indeed, we found that even in the deepest narcosis closure of the glottis 
followed irritation of the interior of the larynx. 

There seems to be a similarity between the nerve fibres of the recur- 
rent and those of the pneumogastric, and, on the whole, we are inclined 
to think that the great irritability mentioned above is in the nerve fibres 
supplying the abductors ; the two sets of fibres of the recurrent supply 
opposite sets of muscles, and may be likened to the two kinds of nerve 
fibres composing the pneumogastric — the one answering to less, the other 
to stronger stimuli. 

Again, it seems to me that the abductor muscles are the more irritable, 
and are always ready to perform their part in the human economy ; that 
the adductor muscles, on the other hand, are less irritable, but none the 
less ready, in consciousness or unconsciousness, to perform their function. 
It is a physiological fact that impulses from almost every sentient surface, 
or passing along almost every sensory nerve, may modify the respiratory 
movements in one direction or the other, the slighter, feebler impulses 
tending to quicken the respiratory discharges ; the stronger, larger 
impulses tending to arrest or inhibit the respiratory discharges from the 



HUTCHINSON, CLINICAL GROUPS OF TUMORS. 103 

medulla ; and the movement of the larynx would be in keeping with 
that of the rest of the respiratory apparatus. 

Finally, the constrictors of the larynx, needing a stronger stimulus to 
bring them into action, find that stronger stimulus in the numerous reflexes 
which arise upon the introduction of any foreign body into that organ. 

My thanks are due to my friend, Professor Martin, both for the use 
of his laboratory and for valuable help. 



NOTES TOWAED THE FORMATION OF CLINICAL GROUPS 

OF TUMORS. 

By Jonathan Hutchinson, F.R.S., LL.D., 

EMERITUS PROFESSOR OF SURGERY TO THE LONDON HOSPITAL. 

(Concluded from page 478.) 

In the preceding parts of my paper, I have insisted upon the im- 
portance of trying to construct clinical groups of tumors, taking as one 
of our chief guides for doing so the special locality from winch they 
spring. A remarkable illustration of the value of this rule has just 
occurred to me. Eight years ago I published the case of a young lady, 
a governess, who had a tumor of the palate which presented very pecu- 
liar features. It was developed on the left side, just at the junction 
between the hard and soft palate. It was indolent and quite painless, 
and although ulcerated in the middle it showed no tendency to fungate 
or bleed. It was, in fact, quite passive in all its characters. It was 
almost circular and somewhat larger than a shilling. In its centre there 
was an ulcer through which the bare bone could be touched. The 
growth had been slowly increasing, I believe, for about two years. The 
indolent induration of this growth closely resembled what we sometimes 
see in a primary syphilitic sore, but the long history put such a diagnosis 
quite out of the question. 

Having never seen anything exactly like this growth, I asked Sir 
James Paget to be kind enough to look at it, and he agreed with me 
as to its great rarity, and in thinking that it was advisable to excise it, 
and, also, in the hope that it was not of a malignant nature. I did the 
operation very freely, cutting round the base of the growth to the bone, 
and then detaching with a raspatory. The actual cautery was freely 
applied to the edges. A portion of bone from the base of the wound 
subsequently exfoliated, but at the end of six weeks healing was com- 
plete. I heard of this lady two years after the operation. She had 
married and was in excellent health without any signs of return. 



104 HUTCHINSON, CLINICAL GROUPS OF TUMORS. 

During the last three months I have had under care a second case, 
the exact counterpart of the preceding. The growth was on the same 
part of the palate. It was hard and bossy, and although presenting a 
deep ulcer, was entirely devoid of irritability and quite painless. It 
had been growing for about two years. I excised it freely, taking away 
the whole thickness of part of the soft palate. The wound has healed 
well, but as yet only four months have elapsed since the operation. 

In neither of these cases was there any gland disease. The subject of 
the second case was a tradesman from Lancashire, aged about forty-five. 
A careful microscopic examination of the growth was made in the second 
case by my eldest son, who reported that it showed evidence of having 
originated in gland tissue, but did not display the ordinary features of 
epithelial cancer. We may regard the growth as adenoid in both cases, 
and as having probably begun in one of the large glands met with in 
this region. The two cases were, I repeat, exact fac-similes of each 
other, and I may add that I have never seen growths precisely like 
them anywhere else. 

Amongst the clinical names which I would not willingly lose is that 
of "warty tumor of cicatrices." No doubt, these tumors do eventually 
assume the histological characters of epithelial carcinoma, but their 
history is usually very different. Their differences depend doubtless 
upon the peculiarities of the tissue in which they take their origin, that 
tissue being a scar. With rare exceptions, malignant growths in cicatrix 
do not cause gland disease. They may run a long course and assume 
very formidable local proportions, but still there is no risk either of 
gland infection or of internal growths. A knowledge of this fact is of 
great importance to the surgeon, and may occasionally encourage him to 
perform radical operations under circumstances otherwise very unhopeful. 
Even if in connection with the unhealthy state of the ulcer there 
should be irritation or enlargement of the lymphatics, there is reason to 
hope that it may subside after removal of the jDrimary disease. All 
that is necessary in order to predicate these peculiarities of clinical 
course, is to be certain that the morbid action did really begin in scar 
tissue. I would be far from asserting that all cancers of scar are exactly 
alike. On the contrary, it is very possible that they may differ in im- 
portant features in different kinds of scar. Thus, when cancer begins in 
the scars left by lupus it has a different course to that which we witness 
when it begins in the scar of a burn. So also when it begins in a scar 
which has previously taken on keloid growth (a rare event) it may 
present peculiarities. When it attacks a lupus scar it usually runs, I 
believe, a very rapid course. Its career is still, however, a local one. 
It fungates, ulcerates, and bleeds, but it does not affect the lymphatics. 

There is certainly important work to be done in the collection of 
clinical evidence as to the diseases to which scar tissue of different kinds 



HUTCHINSON, CLINICAL GROUPS OF TUMORS. 105 

is liable. We shall be unwise if we are content to class all malignant 
diseases of scar as simply epithelial cancer, since we shall fail to indicate, 
under that name, all the knowledge that we possess. The designation 
is too comprehensive, yet it is the only one which histology can give us. 

I was indebted to Mr. Caesar Hawkins for having my attention first 
drawn to the peculiarities of cancer when it begins in scars, and to the 
fact that it does not cause gland disease. So long ago as 1833, Mr. 
Hawkins published in the Medico- Chirurgical Transactions a series of 
" Cases of Warty Tumors in Cicatrices," and he resumed the subject 
again in a clinical lecture in 1837. He insisted strongly respecting such 
growths that although they may grow freely, fungate, and progress 
rapidly, yet " that the disease is not in the least malignant, as cancer is 
malignant, but is, on the contrary, entirely local in its origin, and does 
not contaminate even the adjacent parts, except in a very trifling degree, 
so that no future mischief need be apprehended." In several of Mr. 
Hawkins's cases the scars were of a kind which we now fortunately never 
see, those, namely, which result from the contused lacerations caused by 
flogging. 

I have adverted to the fact that scars from different causes differ 
somewhat in their characters, and that probably each special kind of 
scar stamps its peculiarity on the malignant growth which affects it. 
As a further illustration of this fact, I may adduce a very peculiar form 
of epithelial cancer with which I have only recently become acquainted, 
and which is developed in warty scars in the palm, the consequence of 
prolonged administration of arsenic. My own experience of this malady 
comprises only a single case, but in it both palms were affected, and the 
malignant growth presented the same peculiar features in both. In 
neither, although the microscope gave the verdict " epithelioma," did 
the ulcer look at all like what we usually recognize as epithelial cancer. 
Some of the best authorities who saw the case, and it was seen by many, 
felt confident that the disease was syphilis, and not cancer. In the end 
there remained no doubt on this point, and I mention this opinion only 
in order to emphasize my assertion that the growth did not look like 
cancer. Its peculiar features, which led to the suspicion of syphilis, 
were the entire absence of warty growths, and a condition of infiltration 
of cellular tissue with ulceration of the skin. It may possibly be objected 
that I have no right to claim this growth as originating in scar. The 
state of skin which precedes it, and which is caused by arsenic, is, how- 
ever, really one closely allied to scar. In the first place, little pits are 
developed in the skin of the palm, and after these have lasted for some 
time the epidermis at the borders of the pits becomes hard and horny. 
Next, from the bases of the pits, where the epidermis has been destroyed, 
growth downward takes place, and the malignant disease is developed. 
Although some horny thickening of epidermis occurs in parts, yet from 



106 HUTCHINSON, CLINICAL GROUPS OF TUMORS. 

first to last there are no true papillary warts. Whether or not we admit 
that the disease is cancer of scar, it equally well sustains my contention 
that it is desirable to construct clinical as well as histological groups of 
malignant growths, for it differs widely from all other forms of cancer, 
and its peculiarities are repeated in fac-simile in other examples of the 
same malady. I have said that the two growths were exactly alike in 
the two hands of the patient whose case is the only one which I have 
myself seen. This patient was a New York surgeon, and his case has 
been very ably recorded by Dr. James White, of that city. Dr. White 
has also been able to add another case, in which, in association with the 
same antecedents, an exactly similar growth occurred. The condition 
of atrophic scarring of the palms from the too prolonged use of arsenic 
I have myself repeatedly seen. So far as the facts at present go, I 
believe that they favor the belief that in this form of cancer, as in others 
developed in scars, there is no affection of the lymphatic glands. 

When malignant action attacks the skin of the back or chest it 
usually runs a course very different from the gland-infecting form of 
epithelioma, and somewhat different also from the rodent cancer (which 
does not affect glands). It is certainly more nearly allied to the latter 
than the former. We do not, however, see it travelling over large 
surfaces with its wavy semitransparent edge and superficial growth in 
the manner which we are so familiar with in rodent when it affects the 
skin of the face. On the chest and back the ulceration extends deeply 
and is characterized by extremely thick edges. I have seen a huge 
ulcer with hard edges an inch in thickness, and an area of six inches 
by three, yet no tendency to fungate, no bleeding, no gland disease, and, 
on the whole, comparatively slow progress. Almost all the cases of 
cutaneous cancer in these regions conform to the same type, and this 
type is seldom or never closely repeated elsewhere. On the limbs w r e 
never see any approach to the peculiarities of rodent cancer as seen on 
the face, or to the deep malignant ulcers which I have just been describ- 
ing, on the trunk. 

I believe that we might say that every part of the skin surface of the 
body has its own peculiar tendencies, as regards the types of cancerous 
action which are developed in it. I have already insisted that the rodent 
ulcer is a disease almost restricted to the face. When anything approach- 
ing to it occurs on other parts it always shows special peculiarities. I 
have just alluded to the deep, huge ulcers which form on the front of 
the chest and abdomen. Further observation will, I believe, confirm 
me in the statement that there are distinct features of difference between 
these and malignant ulcers on the back. I have seen four or five in the 
latter region which were all exactly alike. Like rodent, they spare the 
glands ; they are as slow in their progress as is rodent of the face, but 
they assume very different external features. A German lady whom I 



HUTCHINSON, CLINICAL GROUPS OF TUMORS. 107 

am now attending may serve as an example of the local malignant ulcer 
as met with on the back. She is fifty-four years of age, and the ulcer 
has been sixteen years in progress. Although very large, it causes her 
no discomfort, and has not materially injured her health. It is placed 
exactly in the middle of the line between her shoulders, and is upward 
of six inches in length by three in breadth. Its edges are dusky and 
undermined, and more or less ragged. It might, indeed, be taken at 
first glance for a carbuncle which had recently sloughed. From this, 
however, the stony hardness of its borders and base at once separates it. 
It is at least an inch in depth at all parts, but its hollow is crossed by 
thick seamy bands, and there is a decided tendency to contraction and 
puckering. There is no evidence of morbid growth excepting the stony 
induration of the walls of the ulcer. Of the sinuous raised border which 
characterizes rodent there is not a trace. My patient believed that it 
began in a mole " which was white, like a strawberry," but this must 
not be regarded as certain. There is no trace of gland disease, and 
taking the fact of its very long duration, I have no doubt that it is of 
the same nature as rodent, being differentiated by its special position, 
and perhaps by the structure in which it originated. I may assert that 
all the malignant ulcers which I have seen in this position have been 
alike in inveterate tendency to prompt recurrence after excision or de- 
struction by escharotics. I have repeatedly used the chloride of zinc 
paste most freely, but having always been disappointed even of tempo- 
rary good results, have come to the conclusion that by far the kindest 
plan is resolutely to let them alone. This remark, of course, does not 
apply to cases seen in an early stage, but of these none has come under 
my notice. I have seen no ulcers exactly like these on any other region 
of the integument. 

Our forefathers Avere fond of the term " parotid tumor," including 
under it all forms of innocent new growth beginning in or on the parotid 
gland. Some of these growths are cellular only, and others contain 
nodules of cartilage. Explain it as we may, the fact is certain that 
tumors are often seen in this region which run a course somewhat pecu- 
liar. The experienced surgeon knows what to predicate concerning the 
course of a " parotid tumor," and does not expect to encounter similar 
growths elsewhere. Their slowness, yet persistency of growth, the 
absence of tendency to skin implication, aud the enormous size which 
they ultimately attain, are their peculiar features. Certainly they do 
not all begin in the gland. In some cases they appear to overlie it, and 
as they get heavier show a tendency to travel downward on the neck. 
I possess a photograph of such a growth which had in the course of 
twenty years attained a size almost equal to that of the head of the 
old man who was its possessor. During a recent visit to Glasgow, Dr. 
Paterson showed me another photograph — of an old woman, if I re- 



108 HUTCHINSON, CLINICAL GROUPS OF TUMORS. 

member rightly — almost an exact repetition of my own case and with 
a precisely similar history. A patient whom, twenty years ago, I saw T 
in King's College Hospital, under the care of Sir W. Ferguson, pre- 
sented a third example of this kind of growth. In him also it had 
slowly increased for more than twenty years. These tumors, Avhich are 
emphatically innocent, must be carefully discriminated from the rapidly 
growing masses which I described as frequently originating under the 
ster no-mast o id, and which are of the nature of lympho-sarcoma. I pre- 
sume that they are of fibro-cellular structure, with perhaps some nodules 
of cartilage, but I have not had an opportunity for examination after 
removal in any single case. They are encapsuled and might no doubt 
easily be removed in an early stage. When very large it is probably 
wisest to leave them alone. Sir William Ferguson's patient, just referred 
to, had travelled from India for the operation, and, I believe, died after 
its performance. On the other hand, there is the well-known case of 
Hunter's in which a cartilaginous parotid tumor which had been grow- 
ing fifteen years was successfully removed, although it weighed afterward 
144 ounces. Sir James Paget, who has given us much important infor- 
mation as to the structure of parotid growths, states that when they contain 
cartilage it is often mixed with "other tissues and especially with what 
appears to be an imperfect or perverted glandular tissue." Most certainly 
they are not always cartilaginous, and, I think, seldom wholly such, but 
whatever their structure a sldNv course may be confidently predicted, 
and no tendency whatever to implicate other parts. I had recently, at 
the College of Surgeons, an opportunity of examining a man on whom 
the late Mr. Phillips and the late Mr. Hilton had each in succession 
operated for the removal of a parotid tumor. There was an interval of 
three years between the two operations, and since the last a period of 
twenty years had elapsed. The man was in good health, but had suffered 
the inconvenience of complete paralysis of the portio dura ever since 
the last operation. A point of much interest was that at several different 
spots near the scar there were small portions of fresh growth which had 
originated, no doubt, in fragments which had been left behind. None 
of these had grown to more than the bigness of a nut, and all were of 
firm fibrous consistence, but probably not cartilaginous. 

In the condition of disease known as molluscum fibrosum, we have a 
considerable variety of new growth, and it is, I w r ould submit, to be 
desired that it may keep its old name, rather than be merged in some 
wide histological group, and rechristened accordingly. The name now 
in use applies to the total of products which we meet with in the malady 
in question. Part of the disease consists in the formation of fibro-fatty 
masses under the skin (possibly abortive gland tissue) ; these may vary 
much in size, and may dip deeply or rise forward and become peduncu- 
lated. Over these, but quite distinct from them, in many parts are 



CLINICAL GROUPS OF TUMORS. 109 

enlarged sebaceous glands with sebaceous plugs. Another part of the 
disease, which is never omitted, is the formation of little pedunculated 
cutaneous pouches which contain no solid growth, and a third and much 
less common element is papillary hypertrophy. Although never noticed 
at birth, the very early development of the several morbid conditions 
proves conclusively that, the tendency, probably the tumor germs, is 
present congenitally. In addition to the conditions mentioned, various 
secondary changes allied to tumor growth may be observed in this form 
of molluscum, especially when its masses become pendulous. 

Possibly in near alliance with molluscum fibrosum we have the exam- 
ples of multiple fibro-fatty tumors of the extremities. These are most 
commonly seen on the upper extremities, and are arranged symmetri- 
cally. They are often seen in young men, but never, I think, in children, 
and are very rare in women. There is not such strong evidence as 
regards congenital proclivity, as in the case of molluscum fibrosum, still 
the probability is great. Like the latter, there appears to be some law 
of limited growth, for they never, I think, get beyond a certain size. 
These tumors are seen occasionally in the thighs, more rarely still on the 
legs, and very seldom on the trunk, neck, and head. They afford, I 
think, a good instance of the liability of certain regions of the body to 
special kinds of new growth. 

Some years ago I had occasion to remove the entire tongue of a medical 
student on account of a tumor which had very slowly developed in its 
substance, and had finally attained a very large size. It was probably 
an example of lympho-sarcoma, for, although he enjoyed good health 
for two years after the operation, at the end of the period it appeared 
on the floor of the mouth, grew very rapidly, and caused death. My 
reason for mentioning the case here is because this growth had been 
attended by a very peculiar condition of papillary hypertrophy on the 
surface of the tongue. Now the kind of hypertrophy alluded to is not 
very uncommon, and it is, in some cases, congenital. It does not always 
lead to anything of the nature of lympho-sarcoma, but, I believe that, 
if not removed in early life, it does usually to some form of tumor 
growth. The cases are too rare to permit of any very confident state- 
ments, but they are sufficient to justify the acceptance in our clinical 
nosologies of a congenital tumor of the tongue, which sometimes mani- 
fests aggressive tendencies. It is the sameness in origin rather than the 
tissue peculiarities of the final result in an individual case which should 
guide us in naming and classifying such growths. 

The diseases known as keloid and lupus scarcely rank as tumors, but 
they both of them afford such excellent examples of the influence of 
locality in giving peculiarity to morbid growths that I can scarcely omit 
their mention. If we wish to see typical specimens of the spurred keloid, 
such as Alibert first described, w r e must seek it where he observed it, on 



110 HARVEY, HYPERPLASIA OF ORAL MUCOSA. 

the skin of the chest. Not but that fairly well characterized keloid 
growths may be seen in many other parts, but nowhere else does it so 
fully develop its peculiarities. In many others it is distinctly different. 
On the face it is very rarely seen, on the back of the neck it may attain 
great thickness, but is seldom very hard ; in the lobule of the ear it is 
not hard at all, but merely a firm, flabby solid. On the hands and feet 
it is perhaps never seen, and on the legs and arms it is rare, and never 
so hard as when on the chest or back. Lupus exemplifies, in a parallel 
manner, the influence of locality in conferring peculiarities. Note the 
ease with which a complete cure is effected on the arms and legs, as com- 
pared with the nose and face. On the hands and feet nothing that is 
usually recognized as lupus ever occurs, but in its {)lace a sort of inflam- 
matory papillary hypertrophy. The flat, non-ulcerated patch, with its 
thick layer of semitransparent apple-jelly-like tissue, so common on the 
cheeks, is never seen on the hands and feet. Yet that the ulcerations 
with papillary hypertrophy, to which I have just referred as occurring 
in the hands and feet, are really lupus, is proved by their frequent coin- 
cidence with lupus of unmistakable type on other parts. 

In concluding this paper, I wish to make it clear that my object has 
not been to undervalue in any degree the labors of histologists, but 
rather to urge that clinical observers may find useful work in their own 
special field. I have tried to show that by careful case-collecting and 
the selection and grouping of cases, which, as regards locality, cause, 
and general course, are really alike, we may hope to construct, on a 
natural basis, clinical families much more minutely subdivided than is 
as yet possible to the microscopist. 



CHRONIC HYPERPLASIA OF THE ORAL MUCOSA, WITH 
CORNIFICATION OF ITS EPITHELIUM. 

By P. F. Harvey, M.D., 

CAPTAIN AND ASSISTANT SUKGEON, V. S. A. 

Synonymes : ichthyosis lingu?e (8. Plumbe, 1837 ; Hulke, 1861) ; 
plaques des fumeurs (Buzenet, 1858) ; tylosis (Ullmann, 1858) ; keratosis 
(Kaposi, 1866) ; psoriasis buccal (Bazin, 1868) ; papilloma or tylosis 
(F. Clarke, 1873) ; leukoplakia buccalis (Schwimmer, 1877) ; leucoma 
(Hutchinson, 1883; Butlin, 1885); opaline plaques of professional 
glassblowers (Gurnard, A. Clarke) ; plaques nacrees commissuraires 
(Fournier) ; chronic epithelial stomatitis (E. Besnier). 

This formidable array of names refers to a group of closely allied 



OF ORAL MUCOSA. Ill 

affections that have only been recognized as distinct morbid conditions 
within the past twenty-five years, although evidently referred to in one 
form by Samuel Plumbe, in his treatise on Diseases of the Skin, published 
in 1837, in which he stated that he had observed an abnormal develop- 
ment of the papillae of the tongue in a healthy man, which he regarded 
as precisely similar to ichthyosis of the skin. But Hulke, in 1861, 
appears first to have drawn attention to this special form by the report 
of a case upon which he operated and of which he made a minute study. 
This elicited a description of other cases and led to a careful study of 
this and allied affections, by a number of surgeons and dermatologists. 
The result of this combined research has not been to clear up wholly 
the mystery in which the disorders have been enveloped from the first, 
and considerable differences of opinion still exist among authorities 
regarding their true character. 

I have ventured to include all the synonymes under a descriptive title 
which briefly sums up, according to Ziegler, the pathological anatomy 
of the affections, or at least of the leading varieties, those especially that 
tend to run into epithelioma. A name to apply generally is difficult to 
select, as there appear to be several forms of the disease differing in their 
clinical and histological appearances and responding differently to treat- 
ment, but all agreeing in being very chronic and no doubt bearing a 
close relationship to each other. It will be seen, further on, that there 
are grounds for recognizing at least three varieties of the disease and 
possibly a fourth, to each of which a separate name might with pro- 
priety be retained from the foregoing list. 

The disease, in general, is characterized by the appearance of patches 
and streaks or raised areas, on the lingual or buccal epithelium, of a 
whitish, bluish, or yellowish color in different cases, and ranging in 
consistency from that of a piece of wet kid leather to that of cartilage. 
It begins very insidiously, and its early stages generally pass unnoticed 
by the absence of severe subjective symptoms. After the development of 
the first patches new ones frequently form, and it is the evolution of these 
which has been chiefly studied. The earliest morbid appearance, accord- 
ing to Schwimmer, is a red spot due to hyperemia of the superficial bed 
of the mucous membrane ; on the tongue this red spot is usually studded 
with granulations the size of a pin's head, due to the tumefaction of the 
fungiform papillae. In this stage, which may last for several months, 
the implicated epithelium is not altered, but gradually its vitality is 
modified, it thickens, hardens, and changes in color, passing successively 
from bluish-white to grayish- and silvery-white in spots the size of a 
grain of wheat, which spread and become confluent, forming the spot or 
patch that generally comes under the notice of the surgeon. These 
changes take place very slowly. Schwimmer says that so long as the 
lesion is progressive it is surrounded by a narrow hypersemic border, 



112 HARVEY, HYPERPLASIA OF ORAL MUCOSA. 

which disappearing, the extension of the plaque is momentarily or 
definitely arrested. 

If seen at its early stage, well-directed treatment generally removes 
the disease, but unfortunately attention is not usually called to it until 
it has lasted for some time and become more or less confirmed. In one 
form (ichthyosis), the patches are in the form of a thick, fibrous, pearly- 
white covering on the tongue, upon which may be seen lines and striae 
forming polygonal spaces. Ultimately these lines may become fissures, 
which suppurate and become very painful. Another form (psoriasis) 
is characterized by an occasional peeling off or desquamation of the 
involved epithelium, leaving bare, ulcer-like spaces which, later on, are 
again covered over by altered epithelium. All forms of the disease are 
very chronic : any one form may remain stationary, or slowly progress, 
and iu a certain percentage of cases the tendency is to malignancy, 
epithelioma making its appearance at some point of the affected area, 
and running its fatal course with the same rapidity as when brought 
about by other causes. 

This oral disease, in its pathological nature, is unquestionably related 
to psoriasis, ichthyosis, and verruca. The clinical features of one form 
are so similar to those of external ichthyosis as to justify the adoption of 
that name ; of another, the minute anatomy resembles so strongly cuta- 
neous psoriasis that Bazin applied that name to the lingual disease, it 
seems, with entire propriety. Ziegler 1 classes this group of affections 
among the hypertrophies. Debove' 2 is inclined to regard the condition as 
one of cirrhosis. Fairlie Clarke regards its essential nature as a chronic 
inflammation. The initial state expresses no doubt a low grade of in- 
flammation, while the more advanced condition is more probably a 
hypertrophy. 

Let us consider briefly the histological characters of the affections, 
contrasting them with those of the kindred disorders of the skin. 
Debove, whose brochure is based on a study of tw T enty-four cases, made 
microscopic examination of the diseased parts of two cancroidal cases, 
one of the tongue and one of the cheek. The tissues were taken some 
distance from the cancerous deposit, but are supposed to have shown 
changes due to this sequel or complication. He regarded the change as 
a cirrhosis of the lingual mucosa; it was found thickened, indurated, 
and gritty to the knife, with thickening of the epithelium ; here and 
there the nucleolus of the vesicular cells was dilated, and the corium four 
or five times thicker than normal, owing to the presence of dense connec- 
tive tissue. He found a flattening of the papillae, which caused them 
to resemble those of the skin, a dilatation of the vessels and an accumu- 
lation of leucocytes around their calibre. Butlin (p. 148), in opposition 

1 Patholog. Anat., vol. ii. p. 240. 2 Le Psoriasis buccal. Paris, 1873, pp. 54. 



HARVEY, HYPERPLASIA OF ORAL MUCOSA. 113 



to the views of the majority of other observers, believes the epithelium 
to be thinner than normal. 

Schwimmer and Bazin examined specimens taken from the mouths of 
living patients before the onset of malignant symptoms. These authors 
found the fundamental lesion to be an infiltration of young cells in the 
superficial layers of the corium and the top of the papillomatous layer. 
The hyperplasia succeeding the hyperemia was particularly marked 
around the vessels which appeared to be the starting-point of the altera- 
tion. The diapedesis of white blood-globules and the proliferation of con- 
nective tissue cells were equally active. The papillae preserved their indi- 
viduality, if the process was a mild one ; if not, at a more advanced 
stage they became indistinct and were lost in the surrounding tissues — a 
change denoting the conversion of a benign to a malignant action. 

In these descriptions it appears that the pathological anatomy of 
psoriasis is more nearly described than that of any other cutaneous dis- 
ease, and the analogy is still further borne out by the termination of 
external psoriasis in epithelioma occasionally by precisely the same 
steps of transition as observed in lingual psoriasis. Dr. J. C. White, of 
Boston, stated before the American Dermatological Association, at a 
recent meeting, that he had witnessed three cases of cutaneous psoriasis 
terminate in epithelioma, one of which he had previously fully reported, 
with comments, in the American Journal of the Medical Sciences 
for January, 1885. Dr. K. Schuchardtt, in his essay on the "Origin 
of Cancer," 1 reports four cases of psoriasis of the tongue and mouth 
which terminated in carcinoma ; three were inveterate smokers. In a 
syphilitic subject presenting a similar condition, cancer did not appear. 
In another case epithelial cancer developed from a psoriasis preputialis of 
six months' standing. Microscopically the mucous membrane affected by 
psoriasis showed inflammatory infiltration of the superior layers of the 
corium, and in the epithelium were numerous nuclei in a state of active 
proliferation. The application of Paquelin's cautery is especially recom- 
mended by Dr. Schuchardtt as a remedial measure. Case VI. of Weir's 
cases, given in his interesting paper entitled "Ichthyosis of the Tongue 
and Vulva," in the New York Medical Journal of March, 1875, was 
that of a man seen by Dr. Keyes at Hardy's clinic in Paris, who was 
affected with general simple non-syphilitic psoriasis ; a whitened strip 
about one-half inch wide was seen crossing the dorsum of the tongue 
obliquely to its long axis. It was considered by Hardy as part of the 
general eruption, and disappeared with it. Case X. of the same series, 
a psoriatic patient, with the characteristic patches on the tongue and 
buccal surface, was cured by arsenic. Mr. J. Hutchinson has described 
several cases of lichen-psoriasis of the tongue, which seem to correspond 



1 Sammlung klin. Vortr., 257. 
no clxxxiii. — JULY. 1886. 8 



114 HAEVEY, HYPERPLASIA OF ORAL MUCOSA. 

in appearance to the psoriasis of Bazin, at first punctate, and forming 
a patch by confluence. These are much benefited by arsenic. From 
these observations it certainly appears that a belief in the existence of 
oral psoriasis is perfectly legitimate. 

W. Fairlie Clarke 1 found some increase in the thickness of the 
epithelial layer, some enlargement of the papillae, and a great develop- 
ment of the rete mucosum. Around the bases of the papillae and the 
submucous and muscular tissues there was very abundant nuclear cell 
growth. There was also a notable increase in the number and size of 
the bloodvessels of the parts. He illustrated his remarks by mounted 
microscopic specimens. Henry Morris 2 believes the disease to be like 
ichthyosis elsewhere; he has seen it on the tongue, while the neck was 
similarly affected. 

Hulke 3 found the disease he observed, and named ichthyosis of the 
tongue, to consist essentially in hypertrophy of the epithelial and papil- 
lary elements, resembling precisely in its minute anatomy the cutaneous 
disease of the same name. Plumbe also found the disease, as he observed 
it, an almost perfect counterpart of cutaneous ichthyosis, with its epithelial 
proliferation and overgrowth of papillae ; so prominent are these latter 
that they have been characterized as resembling those of the tongue of 
a cat. (Vidal.) 

It therefore appears that this form may be regarded as a variety of 
localized ichthyosis, and its transition to malignancy may be due to its 
peculiar location. To my mind, the reasons for retaining the term are 
more weighty than those which have been advanced for its rejection. 

A milder form of the disease is called by Butlin* "smoker's patch," 
and its more advanced -stage, leucoma. For this variety, however, I 
prefer Schwimmer's term, " leukoplakia buccalis," as it locates the lesion, 
describes its appearance, and does not name another disease; moreover, 
the disease does not necessarily depend upon smoking ; it is rather the 
expression of an irritant acting upon a sensitive mucous membrane. I 
have observed in all cases of hyperesthesia of the mouth and lips a thin, 
sensitive, external skin, with a tendency to congestion of the capillaries. 
All food of a hot or stimulating character, tobacco smoke, or alcohol, in 
such cases, excites a burning sensation of the tongue and roof of the 
mouth, which is apt to persist for some minutes. Acids appear to aggra- 
vate this tendency, and alkalies to relieve it. This, I take it, is the 
predisposing condition to this affection. 

There is still another form of buccal plaque which authors have and 
still regard as belonging to the class of affections we are describing, 
namely, the buccal lesions of tertiary syphilis ; but in my opinion they 

i Med. Times and Gazette, March 21, 1874, pp. 331, 332. 

2 Quart. Journ. Mic. Sci., 1875, p. 07. 3 Med. Times and Gazette, 1865. 

4 Diseases of the Tongue, 1885, p. 127. 



HARVEY, HYPERPLASIA OF ORAL MUCOSA. 115 

should be classed altogether separately, as the disease in question is 
idiopathic, wholly independent of a constitutional virus, is different in its 
physical appearance and in its behavior, and is not in the least benefited 
by specific treatment. Notwithstanding these facts, authors persist in 
ascribing to syphilis the power of causing true leukoplakia buccalis, and 
Kaposi goes so far as to make the mistaken assertion that this disease, 
which he styled keratosis, always has a specific background following 
the opaline plaques of secondary syphilis. The error of this view has 
been abundantly demonstrated, and the tendency of opinion is more and 
more toward a disbelief in the action of a specific cause in any undoubted 
case. When occurring in connection with advanced syphilis it is an 
expression simply of debility, not of the constitutional taint. 

It may not always be perfectly easy in all cases to differentiate be- 
tween the oral manifestations of syphilis and idiopathic leukoplakia or 
ichthyosis, but a correct conclusion can be generally reached by observing 
that the specific lesion is the less obstinate and the more painful of the 
two ; but the question can be definitely settled, as a rule, by the thera- 
peutic test. Iodide of potassium and the mercurials aggravate the 
genuine, but cure the specific disease. 

Two other kinds of patches in the mouth may be encountered, which, 
although not strictly belonging to this class, may be mentioned. The 
action of amalgam fillings in the teeth, when coming in contact with the 
mucous membrane, may cause a whitish aphthous-looking patch from 
epithelial thickening and erosion. This is not leukoplakia, but might 
become so in a person predisposed. Persons who are subject to squamous 
eczema occasionally suffer with peculiar scaly and excoriated patches on 
the tongue. This affection occurs almost exclusively in chlorotic women, 
and becomes aggravated at each menstrual epoch (Keyes). 

Leukoplakia buccalis, and its allied disorders, are very rare. Accord- 
ing to Schwimmer, their relative frequency is 1 in 250 affections of the 
skin. They are unknown in childhood and infancy, but occur most 
frequently between the ages of thirty and fifty. Henry Morris gives the 
extreme ages at which any form has been observed, as twenty-two and 
sixty-seven. Women are almost exempt. Debove did not encounter a 
single case among them in twenty-four cases ; but a few cases are men- 
tioned by other authors, three of which were complicated by the disease 
affecting the vulva. One of these cases was reported by Weir, one by 
Vidal, and one by Schwimmer. 

The etiology of these oral affections differs in different persons ; in 
some, as has been shown, the mucous disease is simply an extension of 
the cutaneous, and being part of the latter, yields to the treatment that 
benefits it. Again, I believe it is possible for a psoriatic or ichthyotic 
diathesis to declare itself in the mouth, and the other parts of the body to 
remain free. As a rule, no tendency to cutaneous eruptions is observable 



116 HARVEY, HYPERPLASIA OF ORAL MUCOSA. 

in persons who become the victims of either of these affections, but a 
sensitive buccal and lingual covering is the predisposing condition, and 
the local action of irritation the exciting cause ; that local irritation may 
be alcohol drinking, tobacco smoking, hot or peppery food, forcible and 
repeated compression of the cheeks against the teeth or other hard 
substance, or, in fact, irritation from any source whatever, if long enough 
continued. 

Most writers believe that the abuse of tobacco is the common exciting 
cause, but when we reflect that nearly all men smoke, and very few 
suffer from any of these affections, and that quite a respectable number 
of cases are on record, occurring in men and women who had never used 
tobacco, and in whom the disease arose apparently from a constitutional 
predisposition only, the action of tobacco smoke as a cause becomes less 
prominent, although in some cases — possibly the majority of a certain 
form — it is undeniably the irritant which excites the diseased action. 
The obscurity as to cause and nature has arisen largely, no doubt, from 
confounding two or three allied but distinct affections. A buccal and 
cutaneous eruption occurring and disappearing simultaneously, I should 
be inclined to regard as identical, or a buccal lesion occurring indepen- 
dently and presenting the scaliness of psoriasis and yielding to arsenic, 
I should certainly regard as a psoriatic manifestation. There is, how- 
ever, a form of the disease which does not present the gross characters 
of psoriasis, ichthyosis, or any external skin disease, occurring in persons 
with perfectly clear skins and no taint of syjmilis, which does not yield 
to constitutional or local treatment. This may be caused by smoking to 
excess, and, as Butlin says, will recover if the inculpated cause be dis- 
continued early ; if the local irritant be continued long enough, the 
disease becomes confirmed, the histological changes occur which are 
persistent and intractable, and may yield to no known treatment ex- 
cept, in favorable cases, to excision or the actual cautery. In this form, 
as perhaps in most forms, the mucous membrane of the tongue and 
mouth is more than usually delicate and sensitive ; objectively there 
may be no special evidence of this, but subjectively there is, the person 
so provided by nature finding that smoking even the mildest kind of 
tobacco will cause a burning or biting sensation of the tongue, and hot 
food cannot be eaten with the same impunity as it can by other persons. 

Lastly, a disordered condition of the digestive apparatus may furnish 
a helping hand in bringing about this intractable disorder ; at all events, 
after the affection is established it is noticeably aggravated by digestive 
and biliary derangements. 

In treatment much depends upon the stage and form of the disease, for, 
as intimated, the diathetic forms and the early stages of the idiopathic 
variety are the more likely cases to be cured by treatment. If we find 
that we have to deal with a gouty manifestation, colchicum and the 



HARVEY, HYPERPLASIA OF ORAL MUCOSA. 117 

alkalies must obviously be our main dependence ; if the disease appears 
in a person much debilitated from any cause, the cause must be sought 
and treated ; if a cutaneous eruption coexists, our remedies should be 
addressed to it as the probable fans et origo mall. If no such indication 
can be found, we may feel pretty confident that constitutional measures 
will avail but little, if at all. Authorities do not all agree that the 
affection in its confirmed idiopathic form is incurable, but such is the 
general opinion, and the main reliance is upon topical measures. In 
the exact use and kind of local applications there is some diversity of 
opinion, but upon one point all agree, namely, in avoiding eschar otic and 
irritant applications. All experience goes to show that caustics increase 
the tendency to a cancerous transformation. 

Hillairet, of Paris, found some alleviation to result from the applica- 
tion of chromic acid (1:8) repeated for three days in succession and 
subsequently at greater intervals. He recommended also rinsing the 
mouth frequently with Vichy water. 1 

Butlin 2 regards the confirmed disease in any of its forms, incurable. 
Palliation by local means is all he admits as possible ; this he finds best 
accomplished by a wash containing to each ounce of distilled w T ater 
either fifteen grains of bicarbonate of potassium, two grains of chromic 
acid, or one grain of bicyanide of mercury, the latter preferably when 
the disease is modified by the syphilitic poison. Weak solutions of 
borax, alum, or common salt he finds of advantage in some cases. The 
mel boracis he thinks best for sore places. The use of the knife he 
limits to thick and circumscribed patches, warty growths, and ulcers 
that are obstinate or show any induration about their bases. These he 
regards as young cancers, and their removal at this early period as the 
only mode of saving the patient from subsequently acquiring fully 
developed and incurable carcinoma. 

Schwimmer, 3 as already stated, believes in the thorough curability of 
the disease during its erythematous stage, and is also hopeful by per- 
sistent treatment of dissipating well-marked whitish plaques of thickening. 
His treatment, as described by himself, does not offer anything specially 
new. Soothing alkaline washes, very weak chromic acid, and sublimate 
solutions gave the best results. Strong applications were in general 
unfavorable ; the temporary palliation produced by a strong solution of 
nitrate of silver did not last, but ultimately tended to aggravate the 
disease. Soothing remedies gave permanent benefit and, he thinks, pre- 
vented, in some of his cases, a change to malignancy. 

Weir, of New York, in a note to the writer, states that in the treat- 
ment of ichthyosis linguae he has practised excision, scraping under the 

1 Trans, of the Seventh Int. Med. Cong., vol. iii. p. 173, 1S81. 2 Op. cit., pp. 152 et seq. 

3 Die iodiopatischen Schleimhautplaque der Mundhole (leukoplakia buccalis), Vierteljahresschr. fur 
Derm, und Syph., 1877, p. 511 ; 1878, p. 53. 



118 

influence of cocaine, and the destruction of the patch by a strong solu- 
tion of chromic acid (60-100 gr. ad §j). When it has lasted for some 
time, and there is any appreciable thickening, he considers excision or 
scraping with a sharp spoon as the best measure. 

Ashhurst (personal communication) advocates the let-alone policy in 
all cases not admitting of excision. 

Heath, 1 in his brief but suggestive account of these affections, describes 
a form of chronic glossitis which, he says, may be caused by stimulating 
food or drink, by over-use of tobacco, by syphilis, or by the prolonged 
ingestion of mercurials. Besides the tongue, it may also attack the 
cheeks. If unchecked, patches may form which peel off from time to 
time and constitute the so-called psoriasis lingual. If still unchecked, a 
more confirmed and serious disorder follows, characterized by the forma- 
tion of permanent whitish patches. This is leukoplakia or leucoma. 
This may pass into cancer. Still more serious is the disease known as 
ichthyosis of the tongue — possibly a later link in the chain of evolution, 
but more probably occurring de novo. Of this form, it is believed that 
it will run with absolute certainty into epithelioma if left to its own 
evolution. He also refers to Hutchinson's description of patches on the 
tongue and cheeks in association Avith external psoriasis and pityriasis. 

We have here a suggestion for an orderly nomenclature and a clearing 
up of the confusion that has hitherto existed, resulting from the attempt 
to explain a group of morbid conditions under a single name, and that 
name a different one with different authors. 

My clinical experience with these disorders is limited to five cases, all 
of the idiopathic form — all males — two in the erythematous stage, and 
three in the stage of whitish plaques. The two former were benefited 
by local treatment and changed habits, and soon passed from under my 
care. Of the three latter, one was in the person of an enlisted man of 
the army, who came only once to my office. On the left side of his 
tongue was a scar which had existed for many years and around which 
a whitish alteration of the epithelium alternated with a reddish and 
painful condition of the mucous membrane (psoriasis). This he had 
observed for several years. At the time I examined it, it was the seat 
of some soreness. I directed him to paint it several times a day with 
the mel sod. borat. He denied ever having had syphilis, but used 
tobacco to excess, as the odor about his person testified. He had also 
been a hard drinker, but had reformed some months before. The second 
case is that of a gentleman who has been under my care for about one 
year. He is a moderate smoker and temperate in the use of liquors, 
and has never had syphilis. The right side of his tongue is affected, 
and he appears to be of a gouty diathesis. Alkalies and colchicum inter- 

1 Internat. Ency. Surg., vol. v. pp. 50 et seq. 



HARVEY, HYPERPLASIA OF ORAL MUCOSA. 119 

nally and alkalies locally have eased him, but his case now remains 
about stationary, occasionally bothering him and again giving him no 
uneasiness. The third case I have had under constant observation for 
over two years. It is one of marked leukoplakia of both cheeks, the 
tongue being wholly uninvolved. Soon after the patient first discovered 
the patches, and before applying for treatment, he touched a part of the 
affected area with nitrate of silver. This place is the only one which 
now seems incapable of being resolved. The other portions have slowly 
improved under treatment, and I am hopeful will, in the course of time, 
return to the normal condition. This patient is wholly free from 
syphilis. He formerly smoked moderately, but wholly abandoned the 
habit two years ago. He also used liquors abstemiously, but now rarely, 
and medicinally if at all. 

The cure of any well-marked case is, to say the least, of doubtful 
attainment, but I would submit the following line of treatment as that 
which my experience and research persuade me to be the most likely to 
secure that end : 

1. Idiopathic and irritative patches, usually expressive of debility, re- 
quire a restorative regimen and tonic treatment. The use of tobacco in 
all forms should be discontinued as much on account of its general as its 
local effect. Alcohol should be interdicted, or used with caution, as 
nothing can be much worse in its local action upon the disease even when 
very much diluted, and I believe its general action to be, in the main, 
unfavorable. Debove regards the morbid change he observed as identi- 
cal with cirrhosis ; how much alcohol may have been concerned in its 
production we can only surmise — that it perpetuates and aggravates it I 
am convinced. All stimulating articles of food, ginger, pepper, mustard, 
carbonic acid waters, hot liquids, hot solids, etc., must be avoided. 
Cold does much less harm than heat, and ice cream, etc., can, as a rale, 
be eaten without injury. The general health should be brought up to 
as high a standard as possible by good food, regularly eaten, suitable 
exercise, frequent bathing, and sufficient sleep. General medication 
should simply be directed toward improving the general health, and 
topical applications need only look to keeping the buccal secretions in 
good condition. This treatment also answers for the disease when 
engrafted upon the anaemic condition of late syphilis, or that arising 
from prolonged use of mercurials. It is, however, always independent 
of specific poison, and must be treated accordingly. 

2. Well-marked patches of leukoplakia should be treated in the same 
way, but we may in addition use weak chromic acid solutions as directed 
by Butlin, advancing by slow degrees to the strength advocated by 
Hillairet and Weir if necessary. This should be done with caution, as 
strong applications are in general unfavorable. In addition, it will be 
perfectly legitimate, I believe, to resort to the constitutional use of 



120 HARVEY, HYPERPLASIA OF ORAL MUCOSA. 

arsenic, at first in tonic doses and afterward carrying it to the point of 
toleration, if necessary, and not otherwise contraindicated. Its thorough 
dilution should be directed, as otherwise it may do harm locally by its 
acridity. Weak alkaline washes should be occasionally used, once or 
twice daily, and it is important that the soothing and restorative plan of 
treatment be followed for years, if necessary. 

3. Ichthyosis of the tongue seems to occur in perfectly healthy and 
robust men, and in its treatment the question of vital repair may not be 
one of so much importance. If the patch is not too thick, it may be 
first brushed with chromic acid solution, 1 : 8, or if not likely to be 
benefited by that application it may be curetted. But, as laid clown by 
Heath, its thorough removal is necessary and, when clearly diagnosti- 
cated, there is no question as to the proper course to take ; it should be 
entirely removed by surgical means — the galvanocautery, the sharp 
spoon, or the knife, for otherwise its transformation into cancer is only a 
question of time. 

4. As the localization of eczema, psoriasis, lichen, pityriasis, etc., on 
the tongue or inside the cheeks appears to be possible, it is well to bear 
this in mind, and if a coincident cutaneous eruption is found it may aid 
us in reaching a diagnosis. 

Finally, an important question is, What cases are likely to undergo 
the epitheliomatous transformation? All writers agree that ichthyosis 
Unr/uce, whether limited or extensive, is a precancerous condition. 
Leukoplakia affecting the tongue is also a forerunner of cancer only a 
little less certain than ichthyosis ; when seated on the mucous lining of the 
cheeks or lips, Debove is of the opinion that it is less apt to display 
malignancy, but Verneuil and Debove each cite one case of cancer fol- 
lowing its localization on the cheek, and Bassenreau one case in which 
the lip was the seat. Psoriasis, as defined by Heath, when properly 
treated may remain benign or undergo a cure, and hence is less apt 
to pass into cancer, but if neglected will probably do so. 

The so-called " smoker's patch," or " smoker's glossitis," or the ery- 
thema of irritation, being the first discoverable morbid state, is usually 
curable by proper treatment, and hence does not express the menace 
that the other forms do. 

Weir thinks that the malignant tendency in any form is directly as 
the epithelial thickening. But simple irritation of the mouth, as of the 
skin elsewhere, if long enough continued, may eventually terminate in 
epithelioma. 

1733 G. Street, N. W., Washington, D. C. 



DALBY, FUNCTIONS OF MEMBEANA TYMPANI. 121 



THE FUNCTIONS OF THE MEMBRANA TYMPANI ILLUSTRATED 

BY DISEASE. 

By Sir William B. Dalby, F.R.C.S., 

AURAL SURGEON TO ST. GEORGE'S HOSPITAL, LONDON. 

The two following considerations will show that our knowledge of the 
functions of the membrana tympani may be added to by the observation 
of this structure when it becomes altered by disease. 1 

1st. Structural changes in the tympanic membrane of a very extensive 
nature may exist without impaired hearing. 

This is shown by examples, in Avhich, after as much as one-half, and 
sometimes more, of its area is occupied with calcareous deposit (phos- 
phate of lime) embedded in its substance, the hearing power remains 
quite normal. With this deposit the membrane is three or four times 
thicker than usual. 

Inasmuch however, as a certain proportion of individuals, who are 
the subjects of this condition, have imperfect hearing, it is a fair pre- 
sumption that in these latter examples the loss of hearing is due to 
changes behind rather than in the substance of the membrane. 

The history of such cases fully bears out this view, for the patients 
w T ith this deposit who hear badly are found to have at some time pre- 
viously suffered from inflammation within the tympanic cavity; so that 
the changes then wrought by this process will sufficiently account for 
the failure in hearing. 

That the position of the obstacle to hearing is in the conducting media, 
and, therefore, in the tympanic cavity, and not in the nervous structure, 
can be in such cases readily demonstrated by experiments with the 
tuning-fork. 

2d. Loss of continuity in the tympanic membrane does not necessarily 
interfere with its function, provided that the ligamentous support which it 
affords to the chain of ossicles is not impaired. 

In several instances where the membrane has been accidentally pierced 
with a very sharp-pointed object — a pin, the hearing has not been found, 
with the most careful tests, to be injured. In these examples the healing 
process occupied from three to four days. 

In one case, when a sudden exj)losion near the ear ruptured the mem- 
brane in two places, the hearing was perfect, and the ruptures healed in 
a few days. This was the only example in which, a rupture having been 
caused by an explosion, the hearing was uninjured. On comparing the 
notes of other cases in which the hearing was injured by explosions, it was 

1 The cases on which the following remarks are based came under the writer's notice between 1873 
and 1885, inclusive. 



122 DALBY, FUNCTIONS OF MEMBRANA TYMPANI. 

found that the hearing suffered more injury when the membrane was not 
ruptured than when it was. It would almost seem from this (if it were 
possible for such an explanation to be accepted) that the force of the 
explosion expended itself partially in rupturing the membrane, and so, 
in a measure, some hearing was saved. At any rate, it appears not an 
unfair conclusion that the loss of hearing must be due, in all cases, to 
damage to the nervous structures ; in other words, to what, for want of 
a more accurate term, must be called shock. 

Certain inferences on the question of loss of continuity may also be 
fairly drawn from instances in which incisions of considerable length 
are made with a sharp instrument (in shape somewhat like a cataract 
needle) for surgical purposes. Such incisions are made in a vertical 
direction and involve nearly the whole length of the membrane from 
above downward in its posterior section. They are made in cases in which 
the cavity of the tympanum has been the seat of inflammation which 
has not caused a perforation of the membrane, and where the effects 
produced by the inflammatory process have been marked rather on the 
lining membrane of the tympanic cavity and its contents than on the 
tympanic membrane itself ; in short, where the thickness of the tympanic 
membrane has not been increased. So far from the incision producing 
a damaging effect upon the hearing, the reverse is the case, the hearing 
power being at once improved the moment that sonorous vibrations can 
pass through the opening. Indeed, were it possible to establish a per- 
manent opening in the membrane, the hearing capacity w T ould be in such 
instances continuously improved. 

That loss of continuity in the tympanic membrane does not of itself 
interfere with its functions is still further shown by the careful and con- 
tinual observation of cases in which the membrane is perforated by 
disease. 

The utmost diversity in hearing power with a perforate membrane 
exists, varying from almost total loss of hearing to a loss so trifling that 
it is detected w r ith difficulty. 

Speaking generally, it may be said that the better degrees of hearing 
will be found where the joerforations are of considerable size, and that 
the sooner the perforation takes place after the inflammatory process 
begins the less damage will be done to the cavity and contents of the 
tympana, and thus to the hearing. To illustrate further my proposition, 
four examples, the counterparts of which have been repeatedly under 
notice, may be instanced and in all of these the tympanic membrane has 
been completely lost by disease. 

In the first the loss of hearing has been total ; in the second the loss 
has been of so trifling a nature as to have escaped observation, and only 
to be detected by the most careful tests with Hughes's sonometer ; in 



STERNBERG, MICROCOCCUS PASTEURI. 123 

the third and fourth the loss has been very great — that is, spoken words 
a few inches from the ear are not distinguishable. 

In the third the application of a small disk of moistened cotton-wool 
adjusted with a probe by the patient, gives (by effecting pressure on the 
stapes) hearing that for the ordinary purposes of life is good. 

In the fourth the contrivance is of no benefit. 

It seems fair, therefore, to infer that the loss of hearing is due to 
causes which do not include the loss of continuity in the tympanic 
membrane. 



MICROCOCCUS PASTEURI. 
By George M. Sternberg, M.D., 

MAJOR AND SURGEON, V. S. A. 

In a paper published in this journal for July, 1885, the writer gave the 
name Micrococcus Pasteuri to a pathogenic micrococcus which was first 
observed by him in 1880, in the blood of a rabbit injected subcutaneously 
with normal human saliva. In the paper referred to, and in a second 
paper published in the October number of this journal, the specific 
identity of this micrococcus with the so-called " pneumococcus " of 
Friedlander was maintained. 

In my second paper I say : 

" In claiming that the micrococcus of Friedlander is specifically 
identical with my M. Pasteuri, it must be understood that I use the word 
species in its botanical sense, and that I recognize different varieties — 
physiological or pathogenic varieties of more or less permanence — of the 
same species." 

I had not at this time seen cultures of Friedlander's coccus, but felt 
justified in assuming specific identity on the grounds stated. I have since 
had an opportunity to compare the Friedlander coccus in pure cultures, 
obtained from Dr. Koch's laboratory in Berlin, with my 31. Pasteuri, 
and I recognize differences which I cannot reconcile with the idea of 
specific identity. 

My inference was based chiefly upon the experimental data showing 
the presence of M. Pasteuri in pneumonic sputum, for I could not doubt 
that the organism which I found in this material and which I tested by 
inoculation into rabbits, and by cultures in liquid and in solid media, 
was identical with the micrococcus which I had so often obtained in 
pure cultures by the injection of my own saliva beneath the skin of a 
rabbit. I am still convinced that this is true, and also that in the ex- 



124 STERNBERG, MICROCOCCUS PASTEURI. 

periments of Talanion * and of Salvioli 2 my M. Pasteuri, and not Fried- 
lander's micrococcus, Avas the organism found in the blood of rabbits 
after inoculation with pneumonic exudate. This is shown by their 
account of the results of their experimental inoculations, which corre- 
spond entirely with my own, whereas the Friedlander coccus does not 
kill rabbits. 

Talamon inoculated twenty rabbits with pneumonic exudate or with 
liquid cultures, and of these all but four died. In the non-fatal cases 
the animals were sick for five or six days and then recovered. Of the 
fatal cases, two presented no alterations of the lungs, which were scarcely 
congested, but a " fibrino-serous pleurisy" and fibrinous pericarditis 
were found. In eight rabbits there was fibrinous pneumonia, sometimes 
involving an entire lung, sometimes only the inferior lobe. In these 
cases also there were pleurisy and pericarditis with fibrinous and serous 
exudation. The blood of the rabbits which succumbed, contained the 
oval micrococcus in abundance. Salvioli's injections of pneumonic ex- 
udate also proved fatal to rabbits, and, as stated, the pathological ap- 
pearances described correspond with those which I have reported from 
similar injections. 

Both of the authors mentioned infer from their experiments that 
croupous pneumonia is an infectious disease, and that the micrococcus 
found by them in the blood of inoculated animals — M. Pasteuri — is 
directly concerned in its etiology. The experimental evidence which 
they offer is quite as good as that upon which Friedlander has founded 
the claim that his micrococcus is the specific germ of croupous pneu- 
monia ; for his experiments upon mice, which furnish the only support 
for this claim, are generally conceded not to be convincing. My infer- 
ence that the organism found by Talamon and by Salvioli in pneumonic 
exudate, was identical with that which I had previously found in the 
blood of rabbits inoculated with normal human saliva, is confirmed by 
the recently published experiments of Frankel. 8 

This author, when he commenced his experiments, about three years 
ago, had no knowledge of my previously published experiments. 4 It was 
by injecting my saliva as a control experiment that I discovered, in the 
summer of 1880, that it contained a pathogenic organism fatal to rab- 
bits. In like manner Frankel discovered that his saliva contained the 
same organism, and, extending his experiments, ascertained that the 
saliva of other persons in health, or sick with various diseases, contained 
the same pathogenic micrococcus. 

i See this journal, July, 1885, p. 114. 

2 G. Salvioli. Natura infettiva della pulmonite crupale. Arch, per le Scienze Med., vol. viii. pp. 
127-148, 1884. 

3 Zeitschrift fur klin. Med., Band X., H. 5 und 6, S. 402-400, 1886. 

4 Published in the Bulletin of the National Board of Health, of April 30, 1881, and also in Studies 
from the Biological Laboratory of Johns Hopkins University, vol. ii., No. 2, 1881. 



STERNBERG, MICROCOCCUS PASTEURI. 125 

The morphological and physiological characters of this micrococcus 
as given by Frankel correspond precisely with my own recorded obser- 
vations, and the figures which illustrate his paper, upon comparison 
with my photo-micrograph published in 1881, will be found to sustain 
the view that the organism as discovered by him in Berlin in 1883, does 
not differ from that which I obtained from a similar source in New 
Orleans in 1880. This is fully recognized by Frankel, who also agrees 
with me as to the identity of this micrococcus with that discovered by 
Pasteur in the blood of a rabbit inoculated with the saliva of a child 
who died of hydrophobia in one of the hospitals of Paris, Dec. 11, 1880. 

Frankel's experiments correspond with my own also in showing a 
difference in the pathogenic potency of the saliva of different individuals, 
and of the same individual at different times. His own saliva was uni- 
formly fatal to rabbits when he commenced his experiments, but a year 
later it was without effect. I also have found a notable diminution in 
the pathogenic potency of my saliva during the past two years. During 
the years 1880-1883 my inoculations almost infallibly caused the death 
of a rabbit within forty-eight hours. During the past two years I have 
had quite a number of failures, and in fatal cases death more commonly 
occurs on the third or fourth day. This result I believe to be due to a 
diminution in the pathogenic power of the micrococcus, rather than to 
its absence at times from my buccal secretions. 

My earlier experiments showed that the blood of an infected rabbit 
just dead, is more potent than a liquid culture, or than saliva contain- 
ing the micrococcus. In short, there is evidence that the organism dif- 
fers in pathogenic power at different times and under different circum- 
stances. 

I have noted that in those instances in which an animal recovers 
after the injection of my saliva, it is found to be immune when sub- 
sequently injected with the more potent virus — blood from a rabbit just 
dead ; and also that a non-fatal attack and subsequent immunity result 
from the injection of infectious material — blood — which has been sub- 
jected to the action of certain chemical agents — sodium hyposulphite, 
and alcohol. 1 In referring to these results in a later publication, I said: 

" It seems probable that a variety of antiseptic substances will be 
found to be equally effective when used in the proper proportion. 
Subsequent experiments have shown that neither of these agents is 
capable of destroying this micrococcus in the proportion used (one 
per cent, of sodium hyposulphite, or one part of ninety-five per cent, 
alcohol to three parts of virus), and that both have a restraining influ- 
ence upon the development of this organism in culture fluids." 2 

The experimental evidence here referred to I believe to be the first 

1 Experiments with Disinfectants. National Board of Health Bulletin, Washington, 1881, vol. iii., No. 
4 ; also Studies from Biological Laboratory of Johns Hopkins University, Baltimore, 1882, vol. ii., No. 3. 

2 Bacteria, Magnin-Stemberg, 2d ed., 1884, p. 207. 



126 STERNBERG, MICROCOCCUS PASTEURI. 

recorded with reference to the " attenuation of virus " by the use of 
chemical reagents. 

Frankel has obtained some interesting results by inoculating rabbits 
in the ear. He has thus produced a local infection, from which the 
animal recovers after a few days, and has proved that it is subsequently 
immune. 

His inoculations into guinea-pigs, fowls, and dogs gave results corre- 
sponding with those previously reported by me — fowls and dogs immune 
and guinea-pigs less susceptible than rabbits. He has also tested the 
pathogenic powers of the organism upon cats, pigeons, and mice. The 
first-mentioned animals are not susceptible, but mice die within forty- 
eight hours after being inoculated. He finds, as I have found, that the 
disease produced by subcutaneous inoculation is at first local, and that 
an inflammatory oedema is induced, which extends in all directions from 
the point of inoculation. General blood-infection does not usually 
occur until a short time before death. I have recently obtained a pure 
culture of the organism by drawing a little serum from the oedematous 
connective tissue, near the point of injection, through a capillary pipette, 
in a rabbit which was still in apparent good health. 

Frankel has always been able to obtain a j)ure culture from blood 
taken from the heart of a rabbit just dead, and it is from this source 
that I have usually obtained my pure stock for experimental purposes. 
He also finds that the organism may be cultivated in veal broth which 
has been carefully neutralized, but that it does not grow at the ordinary 
room temperature. A temperature of 30° to 35° C. is necessary for its 
development. Upon agar-agar, or on solidified blood-serum, it grows, 
within twenty-four hours, in the form of a superficial, nearly transparent 
deposit of gelatinous consistence. In surface culture I have often found 
the organism to form long chains, and, if w T e accept the classification of 
Zopf, it must be assigned to the genus Strejrtococcus. In fluid cultures it 
is commonly found in pairs or in chains of four elements. Frankel 
finds the maximum temperature at which the organism will grow to 
be 42.5° C. 

Very interesting are the results obtained by Frankel in his inocula- 
tions with cultures made at different temperatures, and especially with a 
fluid culture which had been kept at a temperature of 35° C. for sixteen 
days. I quote in full the record of the last-mentioned experiment, in 
which we have evidence of a remarkable modification of pathogenic 
power which is very significant. 

On March 12th, 0.4 c. c. of a pure culture in veal broth was injected 
into the right lung of a rabbit. This culture had been kept in the incu- 
bator at 35° C. since the 25th of February. Temperature of rabbit 
before injection, 39.4° C. ; the following day the same ; March 14th, 
40.7°; March 15, 39.6°; March 16th, dead. Since the preceding day 



STERNBERG, MICROCOCCUS PASTEURI. 127 

there had been severe dyspnoea. At the autopsy fibrinous pleuritis on 
both sides, and fibrinous pericarditis was found. In the right pleural 
cavity only a few drops of fluid exudate. Enormous tumefaction of the 
spleen ; typical cocci in the blood. The inferior lobe of the right lung 
entirely hepatlzed, grayish-red, in part already changed to gray hepatization. 
Sections of granular consistence, as in genuine croupous pneumonia in 
the human lung. The left lung also presented an evident engorgement. 

The results obtained by Frankel with reference to the influence of 
various temperatures on the pathogenic power of this micrococcus are as 
follows : In fluid media a temperature of 42° C, maintained for two 
days, suffices to neutralize the virulence of the culture. The same result 
is obtained at a temperature of 41°, maintained for four or five days. 
Between 39.5° and 40.5° the virulence is no longer abolished, but is so 
far modified that inoculations no longer give rise, in the rabbit, exclu- 
sively to the typical condition of the blood and enlarged spleen of sep- 
ticaemia, but simultaneously to an intense localization of the virus in the 
serous membranes of the heart and lungs. 

In his experimental injections of pneumonic sputum Frankel has 
obtained results identical with my own, detailed in my paper published 
in this journal for July, 1885, and with those of Talamon and of Salvioli. 
He finds that no sputum is more certain to contain this micrococcus than 
the rusty sputum of patients with pneumonia. In the course of two 
years he has made thirty-eight subcutaneous injections into rabbits of 
sputum mixed with distilled water, or w 7 ith a dilute solution of carbonate 
of soda (0.3 per cent.). Twenty rabbits were injected with sputum ob- 
tained from genuine cases of croupous pneumonia between the second 
and sixth day of sickness. Exactly one-half of these animals died of 
typical " sputum-septicaemia ;" the remaining ten were not affected, or 
suffered from other septic processes. The remaining eighteen rabbits 
were injected with the saliva of healthy individuals (five), or with the 
sputa of patients suffering from other pulmonary diseases than pneumo- 
nia — mostly acute or chronic bronchial catarrh. Of these eighteen, only 
three had typical septicaemia. 

Frankel has made a very interesting observation with reference to 
modification of virulence which is in accord with the results of my own 
experimental studies. He finds that the micrococcus does not disappear 
from the sputa of patients with pneumonia after the termination of the 
disease, and has proved by injection experiments that it may still be 
present at the end of some w T eeks. But his experiments show that the 
virulence is no longer so considerable, and that death may occur as late 
as the sixth day, instead of in from twenty-four to forty-eight hours, as 
is the case when the rusty sputum of the inflammatory stage of the dis- 
ease is the material injected. 

The experimental evidence on record shows, then, that M. Pasteuri, 



128 STERNBERG, MICROCOCCUS PASTEURI. 

which is present in the buccal secretions of healthy individuals in vari- 
ous parts of the world, is also found, with greater certainty, in the exu- 
date of croupous pneumonia. Whether it is found in this material 
simply because it is at hand in the buccal cavity, and finds in the 
pneumonic exudate a suitable medium in which to develop, or whether 
it is concerned in the etiology of croupous pneumonia, is an unsettled 
question. We have experimental evidence, however, that this micro- 
coccus does give rise to local inflammation, accompanied with a serous 
or sero-fibrinous exudate, when it is injected into the subcutaneous con- 
nective tissue, or into the pleural cavity of rabbits. 

In my paper heretofore referred to, I have ventured to suggest the 
following hypothesis, which seems to reconcile clinical observations with 
the experimental data, and enables us to account for the occurrence of 
isolated cases of croupous pneumonia, without denying the infectious 
character of the disease. 

" It is established that this is a pathogenic organism, so far as certain 
lower animals are concerned, and that its pathogenic power varies under 
different circumstances. It seems extremely probable that this micro- 
coccus is concerned in the etiology of croupous pneumonia, and that the 
infectious nature of this disease is due to its presence in the fibrinous 
exudate into the pulmonary alveoli. But this cannot be considered as 
definitely established by the experiments which have thus far been 
made upon lower animals. 

" The presence of this micrococcus in the buccal secretions of healthy 
persons indicates that some other factor is required for the development 
of an attack of pneumonia ; and it seems probable that this other factor 
acts by reducing the vital resisting power of the j^ulmonary tissues, and 
thus making them vulnerable to the attacks of the microbe. This 
supposition enables us to account for the development of the numerous 
cases of pneumonia wdiich cannot be traced to infection from without. 
The germ being present, auto-infection is liable to occur when from 
alcoholism, sewer-gas poisoning, crowd poisoning, or any other depressing 
agency, the vitality of the tissues is reduced below the resisting point. 
We may suppose, also, that a reflex vasomotor paralysis, affecting a 
single lobe of the lung, for example, and induced by exposure to cold, 
may so reduce the resisting power of the pulmonary tissue as to permit 
this micrococcus to produce its characteristic effects. 

" Again, we may suppose that a person, whose vital resisting power is 
reduced by any of the causes mentioned, may be attacked by pneumonia 
as a result of infection from without with material containing a patho- 
genic variety of this micrococcus having a potency, permanent or 
acquired, greater than that possessed by the same micrococcus in normal 
buccal secretions." 

This hypothesis does not exclude the view that Friedliinder's micro- 
coccus, and perhaps other pathogenic organisms, may act in like manner. 
We may eventually find that there are various pneumonia-cocci, just as 
we have learned that the pus of acute abscesses contains sometimes one 
and sometimes another coccus, or again two or more in association. It 



MICROCOCCUS PASTEUKI. 129 

can scarcely be doubted that these pus organisms are responsible for the 
local inflammatory changes which give rise to the formation of abscesses. 
But furuncles and abscesses cannot generally be traced to external 
infection, and it seems probable that, as a rule, they are due to auto-infec- 
tion, and that the organisms which produce them are widely distributed 
and always at hand ready to take advantage of circumstances relating 
to the individual which are favorable to their development. In like 
manner general blood infection — septicaemia — may, perhaps, result from 
auto-infection in certain cases. 

The conclusions of Friinkel are in accord with the views stated in 
the above-quoted extract from my paper referred to. This author con- 
cludes his elaborate paper as follows : 

"Finally, as regards the relative frequency of the two hitherto investi- 
gated microbes, in cases of pneumonia, no positive statement can yet be 
made. Nevertheless, I am inclined to regard the lancet-shaped pneu- 
monia-coccus, which is identical with the microbe of sputum-septicaemia, 
as the more frequent and the usual infectious agent of pneumonia, on 
the ground that this organism is so much more frequently found in the 
sputum of pneumonic patients than in that of healthy individuals. This 
conclusion is further supported by the circumstance that it has not 
hitherto been possible to isolate directly from the rusty sputum, Fried- 
lander's bacillus." 

The evidence furnished by Talamon's experiments is decidedly favor- 
able to the view that this micrococcus may be concerned in the etiology 
of croupous pneumonia. Thus Prof. Germain See, in his recent work, 1 
says: 

" The rather brief description of the lesions obtained by Friedlander 
in inoculated mice, leaves some doubt in the mind; for the presence of 
indurated foci — noyaux — in congested lungs does not suffice to charac- 
terize fibrinous pneumonia. But the lungs of rabbits presented by 
Talamon to the Anatomical Society, in support of his communication, 
cannot be the subject of discussion. As he remarks, the appearances 
are not at all those of foci of broncho-pneumonia in a congested lung, as 
one constantly observes in rabbits dead of septicaemia, but a veritable 
lobar fibrinous pneumonia with pleurisy and pericarditis of the same 
nature. The naked-eye appearances, as well as the microscopical ex- 
amination, showed no difference between the lesions produced in the 
rabbit and the pneumonia of man." (Op. cit., p. 92.) 

Evidently Prof. See supposes, as I did for a time, that the micrococcus 
which Talamon encountered in pneumonic exudate, and which produced 
the effects described, is identical with that of Friedlander. That this is 
a mistake is now apparent. No doubt Talamon's results were due to 
the presence of M. Pasteuri in the pneumonic material and culture-fluids 
which he used in his inoculation experiments. This is shown by the 
fact that 16 out of 20 rabbits injected died, while Friedlander's coccus 
does not kill rabbits. Of the 20 rabbits injected directly into the lung, 

1 Maladies Speciflques (non-tuberculeuse) du Poumon. Paris, 1885. 

NO. CLXXXIII. — JULY, 1886. 9 



130 



STERNBERG, MICROCOCCUS PASTEURI. 



8 are said to have presented the lesions of fibrinous pneumonia, 
together with fibrinous pleurisy and usually fibrinous pericarditis. 
" The blood of the rabbits contained the elliptical coccus in abundance." 
Both Friinkel and Talamon sometimes speak of this coccus as lancet- 
shaped or lanceolate. Prof. See says : 

" Seen in the fibrinous exudate, the microbe has an elliptical form 
like a grain of wheat. Cultivated in a liquid medium, an alkaline 
solution of meat extract, it is more elongated and takes the aspect of a 
grain of barley." 

Fig. 1. 




Micrococcus Pasteuri. From blood of rabbit inoculated subcutaneously with normal human saliva. 
Magnified 1000 diameters. From a camera lucida drawing. 

I have commonly spoken of this micrococcus as oval, but in the blood 
or in a rich culture medium, when in active growth, it is often so long 
an oval as to appear lanceolate. (See Fig. 2.) 

Fig. 2. 




Micrococcus Pasteuri. From blood of rabbit inoculated subcutaneously with fresh pneumonic sputum 
from a patient in the seventh day of the disease. Magnified 1000 diameters. From a camera lucida 
drawing. 

On the other hand, in surface cultures it often approaches more 
nearly a spherical form. 

The morphological characters of M. Pasteuri are shown in the accom- 
panying figures, which illustrated my former paper, and which are here 
reproduced for the convenience of readers. 

Fig. 3. 



if W 




Copied from illustration accompanying the paper of Salvioli in the Archivio per le Scienze 3fediche t 
Turin, vol. viii. Fig. 2. "Cells of the pleuritic exudation containing pneumonia-cocci, mounted in 
Canada balsam." Stained with gentian-violet. Amplification not stated (about 1000, G. M. S.). 



MASON, TKAUMATIC NEURITIS. 131 

The mucinous envelope, or " capsule," is very well shown in Fig. 3. 
It has been shown by recent researches that this so-called capsule is by 
no means peculiar to Friedlander's coccus, although it is developed in 
this organism to an unusual extent under certain circumstances — e. g., in 
the blood of an infected mouse. 

Sanger, 1 in a paper recently published, maintains that neither the 
capsule nor the nail-shaped growth in gelatine is peculiar to Fried- 
lander's pneumococcus." This author has isolated five different micro- 
cocci by means of plate cultures, from pneumonic exudate. 

Thost, 2 of Hamburg, has demonstrated the presence of Friedlander's 
coccus in great numbers in the nasal secretions of patients suffering 
from ozaena. It was found in twelve out of seventeen cases, and was 
isolated by Koch's plate method. The coccus obtained from this source 
was proved by culture and inoculation experiments to be identical with 
that described by Friedliinder. It does not kill rabbits, but is fatal to 
mice. These experiments were made in the laboratory of Prof. Frisch, 
of Vienna. 



A CASE OF 
TKAUMATIC NEURITIS OF THIRTY-FIVE YEARS' DURATION. 

TREATMENT BY REPEATED NERVE SECTION ; SUBSEQUENT HISTORY 
AND AUTOPSY. 

By R. Osgood Mason, M.D., 

OF NEW YORK. 

The following case has been observed with interest by many physicians 
and surgeons, during the past fifteen years, both in this country and 
also in Europe ; and reports of it at various stages of its progress have 
been published by Dr. S. Weir Mitchell in the volumes for July, 1874, 
and April, 1876, of this journal, and in the first volume of Brain. The 
case terminated fatally on the 17th of September last, and it is thought 
that an abstract of what has been published, together with a brief his- 
tory of the case during its later stages, and a report of the post-mortem 
appearances, would be of value. 

Miss H. T. when two and a half years of age ran a splinter into the 
palm of the right hand over the point where the median nerve divides 
to send branches to the thumb and fingers. It passed so deeply into the 
hand that it was thought best to poultice and promote suppuration ; but, 
contrary to expectation, the wound healed kindly, and soon all irritation 

1 Bacteriologische Untersuchungen liber die Pneumonie und pneumonische Metastasen. Archiv f. 
exper. path, u phar., B. xx., H. 5 u. 6, 1886. 

2 Pneumoniekokken in der Nase, Deutsche med. Wochenschrift, No. 10, March 11, 1886. 



132 MASON, TKAUMATIC NEUKITIS. 

passed away. The splinter, however, could always be felt, and once, 
when the patient was twelve years old, it was for a time somewhat 
painful. 

At the age of twenty-two years, Miss T., then being in Naples, caught 
hastily the top of a trunk as it was falling forward, and in so doing 
bruised the region in which the splinter lay. Great local pain and 
some swelling followed, which, however, soon passed away, leaving only 
slight uneasiness in the bruised part. Three months later she had pain 
in the right shoulder, which Dr. Suchet, of Paris, regarded as rheumatic. 
In May of the same year, 1871, the pain in the hand grew worse, and 
was severe in the median palm, thumb, and palmar surface of the index 
finger. In August, and later, while travelling, the pain further in- 
creased, extending now to the forearm, and was associated Avith the most 
distressing hyperesthesia. It being now evident that the trouble was 
caused by the splinter, it was removed at Milan, October 22, 1871, by 
Dr. Sapolini, Surgeon to the King of Italy, assisted by Dr. Guerini. It 
was found to lie among the diverging median nerve filaments, and was 
removed with considerable difficulty. 

On awakening from the chloroform sleep the patient w T as at once con- 
scious of intense pain in the forefinger and thumb. Within a few days 
the fingers contracted in a firm flexion, the pain became exquisite, so 
that the least touch was torture. The wound healed in a month, but 
the pain and hyperesthesia were so great as to make it necessary to 
keep the patient almost constantly under the influence of morphia. The 
pain soon extended to the back of the hand, affecting especially the last 
two phalanges of the second and third fingers ; it also passed up the 
forearm ; the shoulder continued painful, and there was severe neuralgia 
in the right side of the face and neck, and even in the right foot. 

During this time she went from one well-known physician to another 
in search of relief. Heat, cold, blisters, electricity, Vienna paste, the 
cautery, and a host of other remedies were successively used, but morphia 
given hypodermically was found to be the only remedy which gave any 
actual relief. 

In November of the same year Dr. Sapolini, after most careful obser- 
vation, found that while continued pressure on the median nerve in the 
forearm only increased the pain, pressure on the musculo-spiral, while 
at first increasing it, after a time diminished, and finally destroyed not 
only the pain but even the sensitiveness, so that the fingers and thumb 
could be roughly handled so long as the pressure was continued. Having 
convinced himself of this fact, he cut down on the musculo-spiral nerve 
above the outer side of the elbow, and removed one inch of it. Perfect 
relief followed this procedure; at the same time, to the amazement of the 
operators, the sense of touch in the radial region of the back of the hand 
was scarcely, if at all, diminished. 

On the eighth day after the operation the pain suddenly came back, 
and while the extreme torture never fully returned, the associated sensa- 
tions and evils grew worse, and, notwithstanding the most skilful efforts 
to sustain it, the health began seriously to fail. 

In 1872 the patient, under the advice of Sir James Paget, was using 
an extended series of hot arm baths, and in February, by advice of the 
same eminent surgeon, she returned to America and placed herself under 
the care of Dr. S. Weir Mitchell, who has ever since taken great interest 
in the case. A full report of his examination and treatment at this time, 



133 

together with the earlier history, is published in the American Journal 
of the Medical Sciences for July, 1874. I will only give sufficient 
here to make the history connected and intelligible. 

At this time, without any notable functional trouble, the patient was 
thin and weak, and singularly liable to sudden flushes or as sudden 
pallor. The hyperesthesia was still extreme, so that day and night her 
chief care was to protect the hand and arm from any possible foreign 
contact. There was considerable loss of power, which Dr. Mitchell re- 
marks was probably chiefly due to the " inhibitory power of constant 
pain." 

Touch and the power to localize touch were normal, except just below 
the scar left by the operation on the musculo-spiral, where touch was 
indistinct and was referred above the scar, and also at some points where 
touch was either felt as both touch and pain or else was in a condition 
of hyperesthesia which entirely overwhelmed the normal sense of touch. 
The great nerve tracts were tender upon deep pressure, and this pres- 
sure over the median and musculo-spiral above the scar caused pain in 
the hand. 

Careful study convinced Dr. Mitchell that the cause of the trouble 
lay in the disordered filaments of the median nerve in the hand, and he 
decided to divide that nerve in the forearm. The operation was per- 
formed by Dr. Brinton, assisted by Drs. Keen and Sinkler, March 2, 
1873. Three-fourths of an inch of the nerve were removed and the end 
of the lower portion was " turned in a transverse direction into the sur- 
rounding tissue "and fixed there by a wire suture. The ends of the 
nerve retracted, so that there was a space of one inch and a half between 
them. The relief from this operation was very marked, and ten months 
later, after giving particulars regarding sensation and motion in different 
parts of the arm and hand, Dr. Mitchell remarks, in closing, " There is 
absolute freedom from pain; the nails grow alike ; the thumb muscles 
are atrophied." 

A microscopic examination of the excised portion of the median nerve 
by Dr. Bertolet, showed disintegration and atrophy occurring primarily 
in the nerve filaments themselves, as distinguished from the disintegra- 
tion and atrophy occurring primarily in the connective tissue of the 
nerve ; that is to say, the nerve was the subject of Wallerian degenera- 
tion. 

As early as 1874 severe pain returned in the line of the incision over 
the musculo-spiral nerve which had been divided by Dr. ISapolini in 
1871. Again every sort of treatment, mild and severe, w r as resorted to 
in order to obtain relief, but without success. At length in March, 
1875, under Dr. Mitchell's advice, Dr. Brinton cut down through Dr. 
Sapolini's old incision. He found the two bulbous termini of the divided 
nerve an inch apart, but thoroughly joined by new nerve tissue. This 
new tissue, the two button-like expansions which it connected, and a 
portion of the original nerve trunk on either side of them, three inches 
in all, were removed. There was at once partial relief from the pain 
and the relief was progressive, so that three months after the operation 
there was no pain at all. 

Miss T. returned to Dr. Mitchell in June, 1877, complaining of great 
pain in those portions of the hand and arm supplied by the median 
nerve. The return of sensation and also of motion by means of galvanic 
excitation made it evident that the nerve had united. Again, under Dr. 



134 MASON, TRAUMATIC NEURITIS. 

Mitchell's advice, Dr. Brinton cut down on the median in the site of the 
old operation, and found the two bulbous extremities of the severed 
nerve. Here also connection had been established, but, unlike the 
former case, the filaments connecting the two bulbs were so small as to 
be scarcely perceptible. They were, however, sufficient to be the bearers 
of the mischievous influence, and it was decided again to sever the con- 
tinuity. Three inches of the median nerve w r ere accordingly removed, 
including the two bulbs with the connecting filaments and a little of the 
original nerve trunk on either side. The result Avas general abolition 
of pain at the surface and impairment of touch in various degrees at 
different points, but there was great pain on pinching or deep pressure, 
and this condition of things remained substantially the same for a con- 
siderable time. 

From June, 1878, to June, 1885, the patient then being in New York, 
was mostly under the care of Dr. Mary Putnam Jacobi, with occasional 
intervals of professional attention from Dr. T. S. Robertson and others. 
Dr. Jacobi has kindly favored me with full notes together with a 
synopsis of the case by periods while under her care, from which I 
have prepared the following condensed statement. 

First 'period — one year, June, 1877, to June, 1878 — was characterized 
by great mental depression from religious excitement, and later by a 
severe attack of acne on the face, lasting three or four months. There 
was, for the greater part of the time, freedom from pain. 

Second period — eighteen months, June, 1878, to Jan. 1880 — charac- 
terized by disturbances of the sexual organs. There Avas a painful men- 
struation following a mild vaginitis, occurring without any known cause. 
There followed symptoms of metritis and ovarian congestion, and these 
w r ere accompanied by leucorrhoea, pain in the left ovarian region and 
intense headache. In March, 1879, there were symptoms of fundal endo- 
metritis, yielding to ergot, iron, and strychnine, followed by an attack 
of parametritis, which yielded to calomel. Later, there was retroversion 
of the fundus uteri, accompanied by congestion of the cervix, and dilata- 
tion of the cervical canal ; and later still, displacement of the left ovary 
behind the uterus, where it was found enlarged and painful. In Jan. 1880, 
by local treatment with iodine, and the use of bichloride of mercury both 
internally and hypodermically, the pelvic symptoms had j)ermanently 
passed away. During this time headache had not been a prominent 
symptom, pain in the hand was slight, but once there was a very severe 
attack of pain in the cervico-brachial plexus, and once a temporary 
return of the mental depression. 

Third period — Jan. to April, 1880 — three months of good health. 

Fourth period — April, 1880 — characterized by a severe illness with 
symptoms of basal meningitis. In going out to church on Good Friday 
the patient complained of the intense glare of the sunlight, making it 
almost impossible for her to see or to keep the eyes open. There was 
the same trouble on her return home. A few hours later she was seized 
w 7 ith violent pain in her eyes attended with generalized headache, vio- 
lent vomiting, and profound prostration. The following symptoms then 
occurred. Two days later there was retraction of the head, with great 
tenderness on pressure in the nape of the neck, and rigidity of the cervical 
muscles. There was intense vertigo on raising the head from the pillow. 



MASON, TRAUMATIC NEURITIS. 135 

The pupils were widely dilated and insensible to light ; vision markedly 
diminished, but no complete amaurosis. Pink suffusion of the conjunc- 
tivas, pulse 100. No rise of temperature. There was no general hyper- 
esthesia, eruption, albuminuria, or enlarged spleen, no special tender- 
ness in the spine below the neck ; there was some deafness in the right 
ear. Recovered in three weeks under opium and iodide of potassium. 
Queries: Was it an optic neuritis (Robertson), or cerebro-spinal menin- 
gitis, or a localized meningitis near the chiasma, or was it a pseudo-in- 
flammatory condition with a hysterical origin? 

Fifth period — June, 1880, to June, 1881 — characterized by symptoms 
of pachymeningitis. The period commenced with constant pain in the 
eyes, greatly increased by attempts to use them ; this pain, much less in 
June and July following the severe illness just referred to, became severe 
in August, and extended to both frontal and occipital regions, occasion- 
ally much exacerbated, and becoming paroxysmal in character. Sleep 
was unusually sound during the night, and there was marked somnolency 
during the day ; nausea in the morning, and a sense of swaying to the 
right side ; tenderness on pressure below the occiput and behind the 
right mastoid process. November 4th the eyes were examined by Dr. 
Noyes. He found hypermetropia and slight astigmatism ; the optic nerve 
in each eye deeply excavated on the temporal side, perhaps normal ; 
deep hyperemia on nasal side, color-field also limited on that side ; veins 
large, arteries small ; debility of the external recti muscles. At an ex- 
amination three years later Dr. Noyes found this weakness of the exter- 
nal recti very marked, and the proper glasses gave marked relief from 
many of her unpleasant head symptoms, and enabled the patient to use 
her eyes with perfect comfort. In December the headaches became 
constant and intense, with frequent acute exacerbations, the pain being 
mostly in the occiput, right temple, and right vertex. Patient has sen- 
sations as if surrounding objects were falling; has disagreeable hallucin- 
ations of sigJit. Pain is decidedly in the right side of the head ; the 
trigeminus of that side affected. Surface temperature of the opposite 
sides of the head compared: left, 91.5°; right, 94.2°. 

Paquelin's cautery was used at the seat of pain with some relief; ice 
was also of use. The fourth cauterization, together with the use of the 
iodide of potassium, was followed by improvement which lasted nearly 
two months, when pain returned in the back of the neck, also violent 
pain in the brachio-cervical plexus, extending down the outer aspect of the 
arm. Cauterization of the neck relieved to some extent, but the pain 
returned in the right side of the head with a sensation of bursting, and 
a return of nausea. Cauterized the scalp, and gaveergotine, with tem- 
porary relief of pain, but peculiar sensations, as of hands tightly grasp- 
ing the knees, heaviness of the limbs, and constant stumbling appeared. 
In May thirty grains of iodide of sodium were given daily with benefit, 
and under this treatment the symptoms permanently disappeared, so 
that the summer of 1881 was characterized by a fair degree of general 
health. 

Sixth period — October to December, 1881 — characterized by first 
appearance of severe nervous dyspepsia. This was relieved by local fara- 
dization, but returned, accompanied by violent headache, and then both 
disappeared with a violent " nerve storm " after faradization of the cer- 
vical sympathetic. 

Seventh period — winter of 1881-82 — characterized by a third attack 



136 MASON, TEAUMATIC NEURITIS. 

of mental depression approaching melancholia. It supervened upon 
a protracted period of fatigue, watching, and anxiety, caused by the 
dangerous illness of the patient's mother. 

Eighth period — November, 1882, to October, 1883 — characterized by 
increase of the dyspeptic attacks. 

Ninth period — October, 1883 — characterized by a return of headache, 
prostration, vertigo, eye troubles (for which Dr. Noyes prescribed), and 
continuation of the dyspepsia. At this time, during Dr. Jacobi's absence 
from the city, Dr. Robertson discovered four per cent, of sugar in the 
urine. It w r as, however, only temporary, and three Aveeks later careful 
examination gave only negative results. 

Tenth period — January, 1884, to June, 1885 — characterized by fre- 
quent attacks of dyspepsia, of varying intensity; one, in January, 1885, 
being of such a character as to remind one of a gastric crisis in locomotor 
ataxia. 

Miss T. came under my care June 9, 1885. The condition of the right 
hand and arm was as follows : They were of a purplish color, cold to the 
touch, and entirely useless. The muscles were atrophied, the whole arm 
small, the wrist dropped, and the fingers were contracted. The hand 
could be slightly extended, but very slowly, and with persistent effort ; 
the thumb, index, and second fingers had no voluntary motion, the ring 
and fourth very little. The forearm could be moved voluntarily, but 
she preferred to move it with the other hand ; the whole arm from the 
shoulder could be freely moved, but without force. There was no con- 
stant pain below the elbow ; sensation in the hand was very poor, so 
much so that it was occasionally cut or burned without being perceived 
at the time, yet foreign contact was extremely disagreeable, and pressure 
or rough handling gave great pain. There had been much more pain 
of a neuralgic character during the year past, so that she began to fear 
a return of all her old torment. Pain in the hand and forearm, however, 
had not been troublesome since the second operation on the median 
nerve in 1877, but she suffered greatly from pain in the head and neck, 
often extending to the shoulder and arm, and sometimes even affecting 
the shoulder and arm of the left side. 

This pain in the head and neck was especially severe. It was increased 
by any sudden movement of the head, by sitting bent forward as in 
sewing, and notably by fatigue or excitement ; on the contrary, it was 
much relieved by rest. 

A second marked and prominent feature of the case at this time was 
a most persistent and distressing dyspepsia. This was indicated by pain 
in the epigastric region very soon after taking food, and by nausea, almost 
always present, but which seldom reached the point of vomiting. There 
was also anaemia, accompanied by great physical weakness, and very 
marked nervous prostration. There was very little of the hysterical ele- 
ment — at least in any of its usual manifestations — in her case; the intel- 
lect was clear, the judgment good, and the will-power strong. The pulse 
and temperature were normal; the alvine and urinary discharges were 
regular and normal, the urine containing neither sugar, albumen, nor 
casts. A fair amount of sleep was obtained, but the nausea returned on 
awakening, and the pain also after taking food, and often remained when 
the stomach was empty. Acne was present upon the face, but was 
unusually developed upon the shoulders and back. 

She w T as treated by rest in bed, carefully selected food in small quanti- 



MASON, TRAUMATIC NEURITIS. 137 

ties ; peptones, bismuth and pepsine, nux vomica, and especially by 
nutrient enemata and quinine also administered by the bowel. 

Some improvement followed, but a little extra exertion brought back 
all the old symptoms in an exaggerated form. Stimulants were appar- 
ently well borne, and were used in regulated doses. In addition to the 
remedies already mentioned, Kumyss, drop doses of ipecac, hydrarg. 
bichlor. in minute doses, dry cups, heat, cold, galvanism applied at the 
epigastrium so as to carry the current through the stomach, were all tried, 
sometimes with some temporary relief, but never with any permauent 
improvement. The bowel was unusually tolerant of enemata, and gra- 
dually, by the end of six weeks, scarcely any nourishment was taken 
except by injections. 

On the 12th of August a violent attack of vomiting occurred, causing 
great prostration. The attack was controlled by suppositories of mor- 
phine and extract of belladonna. After this neither food of any kind 
nor stimulants were taken into the stomach until the last week of her 
life. 

Each enema now consisted of — 

Leube's beef 3yj. 

Whiskey 3iv. 

Water ^j. 

and was administered every four hours. It was well retained and ab- 
sorbed, and the alvine discharges were regular and normal. 

August 18. Pulse 80, regular, and distinct, but without much force ; 
temperature normal. Not a particle of food or drop of stimulant has 
been taken by the mouth for six days ; nevertheless, the distress and the 
nausea continue, and with very little amendment. A little water is the 
only thing which can be taken without causing additional discomfort. 

Peptonized milk was now substituted for a part of the water in the 
enemata. It caused constipation, the eructation of foul gases, and great 
general discomfort. 

August 27 and 28. Each day patient chewed a very small amount of 
beef, swallowing only the juice ; the second trial caused decided increase 
in the distress and nausea, and it was not continued. 

29th. The constipation caused by the peptonized milk gave way, and 
was followed by moderate diarrhoea. Four discharges from the bowels 
and several attacks of vomiting occurred during the night, so that on 
the morning of August 30th I found my patient in a most alarming state 
of collapse. A fair reaction was brought about by means of hypodermics 
of brandy, and later in the day two drops of a one per cent, solution of 
glonoin were added to the enemata, with very perceptible stimulating 
effects. Dr. James R. Learning saw the patient with me in the evening. 

Slst. Nausea still excessive, and vomiting recurs occasionally, but is 
less distressing. Reaction is well maintained ; pulse 112 ; temperature 
99-§-° ; sleeps fairly, one or two hours at a time ; is apathetic, entirely 
without interest in her surroundings 

September 3. Began to complain of imperfect vision, could not distin- 
guish faces; she also has hallucinations of sight, of which, however, she 
is perfectly conscious, and which she describes and laughs over. Bedsores 
are troublesome. 

5th. Sight very bad ; cannot discern colors at all, nor forms with 
exactness. Her hallucinations are very distinct, and present colors. 



138 MASON, TRAUMATIC NEURITIS. 

She describes a row of little green dolls sitting around on the edge of the 
basin beside her ; sees only the lower half of objects. Smell, usually 
very acute, is abolished ; hearing is abnormally acute ; taste normal. 

6th. A decided amelioration of the nausea ; no vomiting for forty- 
eight hours past ; voice stronger ; interest in surroundings has returned ; 
turns on her side, which she has not done before for a week. Special 
senses the same as yesterday ; she is perfectly contented and happy. I 
should say there was decided mental exhilaration, almost flightiness, yet 
when concentrated the mind acts brightly and logically. 

8th. No vomiting; scarcely any nausea; patient is very happy; 
ordered the marketing and preparation of her mother's food as she was 
accustomed to do before her severe illness, and does so with perfect judg- 
ment and propriety. Special senses the same ; pupils natural and con- 
tract in the light ; she scowls at the sudden admission of light ; pulse 
110 ; temperature 99° ; hearing commences to be dull ; manner of talking 
slightly excited. 

9th, 10th, and 11th. Patient continues much the same. She caters 
for her mother, recognizes her friends by voice ; no nausea or distress 
of any kind. Teaspoonful doses of meat juice were taken and enjoyed, 
producing neither nausea nor pain. 

12th. Slept unusually long and soundly last night and is still som- 
nolent. She is easily aroused but the intellect is dull ; she is cheerful, 
has no distress, nothing troubles her ; ordered the marketing and talked 
pleasantly about it ; all the special senses dull except taste. 

llfth. Pulse 130 ; temperature 99° ; respiration 30. Dr. Noyes saw 
the patient and examined the eyes ; result negative, except that there 
was hyperemia of the nerve. 

loth. Very difficult to arouse, respiration sighing. Has passed no 
urine in twenty-four hours ; drew off a pint and a half. Specific gravity 
1.026, no albumen, no sugar, no casts. 

16th. Much the same as yesterday ; no paralysis ; sphincters not re- 
laxed. At 10 p. m. respiration 8. 

l'lth. 12.10 A. M., respiration 7 and easy. 12.40 A. m., it ceased suddenly. 

Autopsy, thirty-six hours after death, was conducted by Dr. R. W. 
Amidon. * Present : Dr. W. T. White, Dr. Geo. W. Leonard, and Dr. J. S. 
Hill. Rigor mortis well marked, emaciation extreme. There was very 
marked atrophy in both the flexor and extensor regions of the forearm, 
and in the extensor region of the arm. The right thenar eminence had 
almost entirely disappeared. Circumference of the arms compared was 
as follows: right arm biceps, 6J inches, left, 6| inches; right forearm, 
5i inches, left, 6f inches. Scars from the different operations distinct. 
The brain and spinal cord were carefully examined, but neither pre- 
sented any appreciable gross lesions. The nerves of the right arm 
w T ere examined with the following result. Dividing the tissues over 
usual course of the median nerve in the region of the scar no nerve 
was discovered ; but after prolonged search the termination of the upper 
portion of the divided nerve was found at a point two inches above the 
scar, and at the extreme ulnar edge of the interosseous space. The nerve 
terminated with the usual bulbous expansion, and with no nerve filaments, 
however minute, apparently extending from it in any direction. The most 
thorough search from this point down to the annular ligament failed to 
discover any trace of the lower portion of the nerve. Search was then 
made for the musculo-spiral nerve. The termination of the upper por- 



139 

tion of this nerve was also found retracted to a considerable distance 
above the scar and far around on the inner aspect of the humerus. It 
also ended in a large bulb with no trace of any filaments going out from 
it in any direction. After careful search the lower portion was found 
nearly in its normal course, but retracted downward so that the distance 
between the ends of the severed nerve was fully three inches. The lower 
portion of the nerve terminated without any expansion and was ap- 
parently even diminished in size. Both the median and rnusculo-sj)iral 
nerves were removed from the point of section almost to the spinal cord, 
and also a portion of the median nerve of the left arm, which, together 
with the brain and spinal cord, were preserved for further examination. 
The abdominal organs were found to be in a healthy condition. The 
stomach was empty and without any appreciable morbid change. The 
pelvic organs were examined in situ, and presented no morbid changes 
except a small cyst the size of a split pea on the posterior wall of the 
uterus. Thoracic organs not examined. 

Dr. R. W. Amidon has carefully attended to the pathological work 
and furnishes the following report of the microscopic examination. 

" The enlargement at the end of the musculo-spiral nerve was three 
centimetres long and kidney-shaped ; that at the end of the median 
nerve was two centimetres long and fusiform. The latter alone was ex- 
amined. It consisted almost entirely of highly developed connective 
tissue, apparently of considerable age and slow formation. Here and 
there, principally at the surface of the tumor, remained traces of bundles 
of nerve fibres which contained, for the most part, granular detritus and 
neuroglia tissue. Occasional apparently healthy nerve fibres were seen. 

" A section of the median nerve about two centimetres above the neu- 
roma revealed the following changes. 

" The sheath of the nerve, together with that of the component bundles 
of the nerve, was a trifle thicker than that of the opposite healthy 
median nerve, there were in these different connective-tissue coverings 
more young cells than would normally exist in such tissue. The fasciculi 
of the nerve contained many perfectly healthy nerve fibres, but these 
were irregularly interspersed throughout the bundles, patches, and tract, 
where normal nerve fibres were replaced by degenerated nervous tissue, 
and a proliferation of neuroglia elements existed throughout the bundle ; 
which changes point to a diffuse, subacute, inflammatory process, and a 
degeneration, confined to certain, probably sensory, groups of fibres. 

" Sections of the three nerve trunks in the axilla presented the same 
changes in many, but not all, fasciculi. Here, as below, the degenerative 
changes were pretty diffuse, at the same time leaving intact very many 
nerve fibres. 

" Sections of the spinal cord, above, below, and at the point of emer- 
gence of the brachial nerves, show no lesions whatever. 

" Sections in the medulla, through the pneumogastric and hypoglossal 
nuclei, when compared with normal sections in the same region, show 
no appreciable change. 

" Sections of occipital convolutions appeared normal." 

The changes here found belong simply to an ascending neuritis, in- 
volving only the trunk and peripheral nerves without invading the cord, 



140 MASON, TRAUMATIC NEURITIS. 

and no pathological changes appear in the brain or medulla. So what 
was the nature of the mischievous influence which caused the serious 
and finally fatal disturbances which occurred in the latter development 
of the disease, is not clear. It can scarcely be doubted, however, that 
in some way they were due to the same cause which wrought so much 
evil in the early history of the case, and the destructive work of which is 
so clearly traced through the nerve trunks quite to the spinal cord. How 
that cause made its influence felt in the distant and internal organs sub- 
sequently invaded, whether in some way it continued on by the cerebro- 
spinal system, or changed its course to the sympathetic, is not easy to 
decide. 

The symptoms developed in the different internal organs, while of a 
distinct and well-defined character, lacked the distinctive features of an 
inflammatory process ; and the post-mortem examination gave no evi- 
dence of any inflammatory process having taken place in any one of 
them. But upon the supposition that the disease, which early caused 
so much mischief in the trunk and peripheral nerves, chose the ganglionic 
system for its subsequent progress, we might expect severe congestions 
to occur in the organs which were influenced by the different ganglia 
as they successively became the subject of either inflammatory or degene- 
rative changes. 

Dr. Jacobi suggests a series of vasomotor paralyses as best explaining 
the series of distressing symptoms which occurred while the case was 
under her care. 

Dr. Dumenil, of the Hotel Dieu de Rouen, in the Gazette Hebdomad aire 
for January, 1866, reports a case presenting points of interest in con- 
nection with the one here described. I shall be pardoned for briefly 
referring to it. 

A healthy laboring woman, thirty-six years of age, rode on a hard seat in 
a jolting wagon, sitting four hours continuously on the right buttock in such 
a way as to make constant pressure on the sciatic nerve of that side. Numb- 
ness was felt at the time, a neuritis was commenced which involved first the 
lower and then the upper extremity of the right side, causing pain, atrophy, 
flexions, and partial paralysis. Then there was a period of improvement in 
the condition of the affected muscles, and a fair condition of health, followed, 
after nearly four years, by the same series of symptoms and lesions in the 
lower and upper extremity of the left side. The lips, tongue, pharynx, and 
larynx were also involved. The case terminated fatally about six years from 
the time of the injury. Two months before death epigastric pain and per- 
sistent vomiting become prominent symptoms ; there were also hiccough and 
distressing contractions of the diaphragm. Treatment was of little avail. 
Electricity increased the pain, and did no good. The vomiting was entirely 
uninfluenced by remedies. The patient died of exhaustion and dyspnoea. 
The vomiting ceased two days before death. The intellect was clear to the 
last. 

Post-mortem examination showed atrophy of the affected muscles, changes 
both inflammatory and degenerative in the large trunk and peripheral nerves, 
and localized degenerative changes scattered at irregular intervals throughout 
the gray substance of the cord and the adjacent white substance. 



141 

In neither of these cases was the pneumogastric nerve examined, nor 
the ganglia of the sympathetic. Is it not probable that careful research 
in that direction, in similar cases, might be productive of interesting 
results ? 



THE SUEGEKY OF THE PANCEEAS, 
AS BASED UPON EXPEEIMENTS AND CLINICAL EESEAECHES. 1 

By N. Senn, M.D., 

ATTENDING SURGEON TO THE MILWAUKEE HOSPITAL ; PROFESSOR OF THE PRINCIPLES AND PRACTICE OF 

SURGERY AND CLINICAL SURGERY IN THE COLLEGE OF PHYSICIANS AND SURGEONS, 

CHICAGO, ILLINOIS. 

In the following article, an attempt will be made to lay the founda- 
tions for a rational method of treatment of some of the injuries and 
diseases of the pancreas by direct surgical measures. The literature on 
the surgery of the pancreas is exceedingly scanty and loosely scattered 
through the medical journals and text-books, as no previous attempt has 
been made to arrange the material in a systematic form for ready refer- 
ence. Our present knowledge of the surgical treatment of diseases of 
the pancreas, is limited to a few operations performed for the cure of re- 
tention c} T sts, by excision or the formation of an external pancreatic 
fistula. The clinical material which I have collected, and more particu- 
larly the description of pathological conditions found within and around 
the pancreas at post-mortem examinations, will be utilized for the pur- 
pose of pointing out new indications for operative interference, by such 
methods as will suggest themselves from the results obtained by experi- 
ments upon animals. 

Experiments on the Pancreas. 

The operative treatment of injuries and diseases of the pancreas be- 
longs to the future. Until now, the efforts of surgeons have been 
limited to the treatment of a few cases of cysts of the pancreas. The 
results obtained in these cases have been so encouraging, that undoubt- 
edly other lesions of this organ will soon constitute new indications for 
surgical treatment. 

The clinical material that is now available is inadequate to furnish a 
reliable basis for new operatious; on this account it has been my object 
to obtain new light by subjecting the pancreas to a variety of surgical 
procedures, to ascertain the tolerance of this organ to direct treatment, 
and to determine, if possible, how much of the gland could be removed 
safely in case it is the seat of injury or disease. The object of these ex- 
periments also included an attempt to elucidate some of the causes and 

1 Bead before the American Surgical Association, Washington, D. C, April 20, 1886. 



142 SENN, SURGERY OF THE PANCREAS. 

pathological conditions of some of the well-recognized lesions of this 
organ. 

Dogs and cats were used exclusively as objects of these experiments, 
as a few trials soon satisfied me that in the smaller herbivora, as the 
rabbit and sheep, the pancreas was proportionately small and difficult 
of access. The operation was always performed under antiseptic pre- 
cautions, with the exclusion of the spray, and the typical orthodox 
dressing. The abdomen was always shaved and disinfected with a solu- 
tion of corrosive sublimate, ether was used as an anaesthetic. The ab- 
dominal incision was made through the linea alba, from near the tip of 
the xiphoid cartilage to the umbilicus. 

The omentum major was either pushed upward, or, in the majority of 
cases, an opening was made into it by tearing at a point opposite the ex- 
ternal incision. The guide to the pancreas was always the pyloric 
orifice of the stomach — after the index finger had reached this point, it 
was passed along the duodenum for three or four inches, when the bowel 
was grasped between the index finger and thumb and brought into 
the incision with the pancreas. If any considerable prolapse of the 
viscera was made necessary to accomplish the object for which the 
operation was made, the exposed organs were carefully protected with a 
compress of gauze wrung out in a warm weak solution of corrosive sub- 
limate (1:2000). Irrigation of the external wound and the protruded 
organs was frequently resorted to with the same solution, to cleanse the 
parts of blood, and to preserve the wound in an aseptic condition. A 
good light and an empty stomach facilitated the operation greatly. 

It was always found difficult to detach the pancreas from the duode- 
num without incurring a considerable and often dangerous loss of blood. 
To prevent this occurrence most effectively, blunt dissection and direct 
compression with a moist, hot, aseptic sponge, proved the most effective 
measures ; when large vessels were to be divided double prophylactic 
ligation was often resorted to. After completion of the operation the 
pancreas and duodenum were thoroughly cleansed and dried, and the 
toilet of the peritoneal cavity made with care, the abdominal incision 
was closed with interrupted sutures, introduced in the usual manner so 
as to include the peritoneum. The external wound was sealed with a 
small compress of iodoform cotton repeatedly saturated with iodoform 
collodium. At the end of a week the sutures were removed. Primary 
union of the abdominal incision was the rule, only in a few instances 
was healing of the w T ound accomplished by granulation. Ventral hernia 
was observed in a number of cases. 

Complete Section of the Pancreas. 

Complete section of the pancreas was made an object of experimenta- 
tion, to ascertain whether the continuity of the pancreatic duct would 



OF THE PANCEEAS. 143 

be restored after complete division and subsequent accurate coaptation, 
and to study the process of repair between the divided ends of the pan- 
creas. The section was made transversely, and, after arresting all 
hemorrhage, the margins of the wound were brought into accurate 
contact with deep catgut sutures, which were made to embrace the 
entire thickness of the organ. 

Experiment I. — Dog, four and a half months old ; weight, 35 pounds. 
Operation performed August 23, 1885. Complete division of pancreas trans- 
versely through the middle portion ; vessels ligated with fine catgut, the 
hemorrhage being arterial from the gastro-splenic, and venous from the 
duodenal end. Cut surfaces brought together accurately with thin catgut 
sutures, which were passed through the entire thickness of the organ, about 
one-third of an inch from the margins of the wound. Animal showed no 
signs of suffering or disease after the operation, but lost four pounds in 
weight during the first eight days. After this time the animal again began 
to increase in weight. Highest temperature 104° F., on the fourth day. Animal 
killed December 6, 1885, 105 days after the operation. 

An examination of the pancreas showed that union had taken place between 
the two ends by means of a narrow cicatrix, which was indicated by a slight 
constriction at the site of section. Duodenal portion of gland presented a 
normal appearance, as the section had been made on the splenic side of the 
common duct. Gastro-splenic end somewhat atrophic and sclerosed. Pan- 
creatic duct patent to cicatrix, where the principal duct of splenic portion 
was completely obliterated. No dilatation of duct in splenic end. 

Experiment II. — Adult dog, medium size ; complete section of pancreas 
through the junction of the middle with the splenic end. Only artery from 
splenic end required ligation. Immediate coaptation by means of three 
catgut ligatures passed through substance of gland. Animal remained well 
after the operation; appetite unimpaired. Dog w r as killed three weeks after 
the operation; abdominal wound completely healed; at point of section 
slight adhesions to neighboring organs. Visceral wound healed by a linear 
cicatrix of young connective tissue. Pancreatic duct completely obliterated 
at site of operation. 

Remarks. — These operations would tend to show that complete 
division of the pancreas, if not complicated by other and more serious 
lesions, is not a dangerous accident, if the only source of danger, hem- 
orrhage, is met by proper surgical treatment. The coaptation of the 
divided ends would be desirable, but is not essential, as the continuity 
of the duct is not restored after this injury. No disturbance of digestion 
was observed in either case, as an adequate amount of pancreatic juice 
was secreted from the portion of the gland which remained in commu- 
nication with the lumen of the intestine. As in both of these instances 
a greater or less amount of pancreatic juice must have escaped into the 
peritoneal cavity from the cut surfaces, and perhaps later from the 
divided duct of the splenic end, we have thus early evidence of the 
innocuity of extravasation of pancreatic juice into the peritoneal cavity. 
The process of repair was in both instances accomplished by the inter- 
position between the divided and coaptated ends of a linear cicatrix. 

Although accurate approximation was effected by three sutures, trans- 
fixing the entire thickness of the gland by passing the needle from be- 



144 SENN, SURGERY OF THE PAXCREAS. 

fore backward on one side, and from behind forward on the other, it 
seems that primary union between the divided ends failed to take place, 
and that the process of repair was accomplished by connective tissue 
proliferation, from the connective tissue on the surface of the wound, a 
process necessarily accompanied by a simultaneous degeneration of the 
parenchyma of the gland, over an area corresponding to the seat of 
cicatrization. 

Microscopical examination of the sections made in close proximity to 
the cicatrix, showed various degrees of degenerative changes in the cells 
of the parenchyma, with a corresponding space of connective tissue pro- 
liferation. 

Complete section of the duct, even when the ends are kept in accurate 
coaptation, appears to result uniformly in the obliteration of the duct at 
the site of section. The obliteration is the direct result of the formation 
of a cicatrix in the lumen of the duct from the cut surfaces. In both 
specimens the length of the cicatrix, consequently the extent of imper- 
meability of the duct, correspond to the length of the cicatrix interposed 
between the divided ends of the gland. 

The practical deductions to be obtained from these experiments are: 
that in transverse visceral wounds of the pancreas, the most important 
indication that presents itself, is to arrest hemorrhage by ligating the 
bleeding vessels, and to resort to suturing of the severed organ with a 
view to retain both ends of the pancreas as nearly as possible in their 
normal location, and thus maintain as nearly as possible the integrity 
of the vascular supply, rather than with a purpose to obtain restoration 
of continuity of the divided pancreatic duct, which, if it could be 
accomplished, would preserve the physiological importance of the de- 
tached portion of the gland. By the detached portion of the gland, I 
mean that portion which no longer remains in physiological connection 
with the intestine, and which never regains its physiological importance 
after the duct has become obliterated by a cicatrix at the point of 
section. 

Laceration of the Pancreas. 

Having observed that complete section of the pancreas is followed by 
severe hemorrhage, both arterial and venous, which undoubtedly might 
prove a source of no inconsiderable danger in cases of similar wounds of 
the organ in man, the following experiment was made to ascertain the 
extent of hemorrhage after laceration of this organ, without the inter- 
vention of treatment. 

Expeeiment III. — Large adult cat ; weight, 7 1 pounds. Abdomen opened 
through the median line, the pancreas exposed and detached sufficiently 
from the duodenum at the junction of the middle with the duodenal end, 
where it was torn completely across and the bleeding ends dropped into the 
abdominal cavity ; the wound was closed in the usual manner. 

The hemorrhage was noticed to be much less than after section. Highest 



145 

temperature 104.6° F., two days after operation. No symptoms of hemor- 
rhage or peritonitis. Oct. 11, sutures were removed, the abdominal incision 
having apparently closed. Oct. 17, the wound opened, and it was reported 
that one end of the pancreas had protruded from the wound. The prolapsed 
viscus and wound were disinfected, the organ replaced, and the opening 
closed with sutures. 

The animal did not appear to be very ill, but died two days later. At the 
autopsy no effusion was found in the peritoneal cavity and no signs of general 
peritonitis. A portion of the duodenum appeared gangrenous. The lacerated 
end of the splenic portion was adherent to the duodenum at a point two inches 
below the pyloric orifice of the stomach. The duodenal portion was very much 
atrophied and drawn up toward the splenic portion, and united to it by an 
extensive mass of cicatricial tissue. On opening the pancreatic duct from the 
duodenum, no communication could be found between it and the gastro- 
splenic portion of the gland. 

Death in this case resulted in the accidental reopening of the abdomi- 
nal wound. The prolapsed organ was, in all probability, the duodenum 
and not the pancreas ; the gangrene of the intestine undoubtedly was 
caused by the prolapse and strangulation before the bowel was replaced. 
The laceration of the pancreas was made at a point where the two ducts 
meet ; hence the impermeability of the duct in the gastro-splenic por- 
tion of the pancreas. Hemorrhage was arrested spontaneously, and the 
process of repair, so far as the wound in the pancreas was concerned, 
appeared to be satisfactory. The divided ends were displaced consider- 
ably immediately after the laceration, but were subsequently brought 
into close contact by the cicatricial contraction. 

Comminution of the Pancreas. 

It has been asserted by a number of authorities that dead pancreatic 
tissue is a highly putrescible substance, and on this account its presence 
is very liable to serve as a source of infection. 

Believing that putrefaction can never occur without the specific germs, 
even in the case of dead and highly putrescible substances, the following 
experiments were made to test the correctness of this assertion : 

Experiment IV. — Maltese cat; weight, 3| pounds. Operation September 
18, 1885. The pancreas, with its vessels, was completely detached from the 
duodenum to the extent of two inches, about the middle of the gland. The 
isolated portion was completely crushed between the blades of a sequestrum 
forceps. No hemorrhage whatever occurred, and the organ was dropped into 
the abdominal cavity. The day after the operation the temperature rose to 
105° F., but the next day it was normal, and remained so until the killing of 
the animal, December 13, eighty-six days after the operation. No evidences 
of diffuse peritonitis, only slight adhesions where the gland had been crushed. 
The duodenal portion was atrophied and drawn toward the gastro-splenic por- 
tion, to which it was united with a firm cicatrix, which united the two ends of 
the gland to the duodenum, thus completing the mesenteric attachment of the 
bowel. The cicatrix showed a line of pigmentation throughout its entire 
thickness. The crushed portion of the gland had disappeared entirely by ab- 
sorption, and its place was occupied by a firm cicatrix, which, by contraction, 
had approximated both portions of the gland. The crushing was done below 
the point of entrance of the pancreatic duct, which caused the atrophy of the 

NO. CLXXX1II. — JULY, 1886. 10 



146 

duodenal portion, which was no longer in physiological connection with the 
duodenum. 

Experiment V. — Young cat ; weight, 2 J pounds. Pancreas brought into 
the abdominal incision, with a loop of the duodenum, and without separating 
it from the bowel it was crushed at its middle to the extent of two inches 
between the blades of a sequestrum forceps. No hemorrhage followed the 
procedure, and the organ was dropped back into the abdominal cavity. The 
animal had been in bad condition before the operation, and died seven days 
later. At the autopsy the abdominal incision was found closed. No peri- 
tonitis or elfusion. Crushed portion showed no signs of suppuration, but 
appeared thicker and shorter than after the crushing, a change which was 
attributed to the infiltration of the dead tissue by leucocytes and connective 
tissue proliferation. The two ends of the glands were brought into closer 
contact by contraction of the recent cicatrix, which had also the effect of 
doubling the duodenum upon itself. 

Remarks. — In both instances the crushed parenchyma of the organ 
was promptly removed by absorption, which seems, in this particular 
locality, to proceed with unusual activity, an occurrence which can only 
be explained by the assumption that the peritoneum is active in this 
process. No infection took place, and no evidences of putrefaction 
could be found. Should wound infection take place in cases of this 
kind, there can be no doubt that the dead pancreatic tissue would serve 
as a most favorable soil for the septic germs, and would thus create the 
most essential condition for rapid and most dangerous form of infection. 

These experiments also serve to demonstrate that subcutaneous crush- 
ing or comminution of the pancreas is in itself not a fatal or even dan- 
gerous injury. Subcutaneous comminution can only prove dangerous 
by the site of the injury, as when, for instance, the crushing takes place 
at or near the outlet of the pancreatic duct, where, from cicatricial con- 
traction, obstruction of the duct takes place which would interfere with 
the normal escape of pancreatic juice from the intact portion of the 
gland. If the comminuted tissue remains in an aseptic condition, it is 
removed by absorption, and the loss of substance is at least partially 
replaced by connective tissue, which forms a bridge between the intact 
portions of the gland. Subsequent degeneration, atrophy, and sclerosis 
take place in that portion of the gland which is no longer connected 
with the intestine by a permeable duct. 

Complete Extirpation of the Pancreas. 

A diversity of opinion still prevails among physiologists in regard to 
the immediate and remote effects of complete extirpation of the pan- 
creas, or an artificial sudden suspension of its functions. The results 
obtained by different experimenters have led to diverse conclusions. 
Some claim for the pancreas an essential part in the process of digestion, 
while others affirm with equal positiveness that the gland can be removed 
or rendered physiologically incompetent without impairing digestion. 
Bernard found that extirpation of the pancreas in birds j^roduced death 
by marasmus in eight or ten days {Mem. sur le Pancreas, p. 157). 



SENN, SURGERY OF THE PANCREAS. 147 

Berard and Colin removed the pancreas in a duck, and, on examin- 
ing it six months later, found the site of the pancreas occupied by a 
thin layer of fat, which contained a few reddish nodules. No connection 
could be traced between them and the intestine. In pigs, part of the 
pancreas lies upon the portal vein, and the authors therefore removed 
only the portion adjacent to the duodenum. In one animal which died a 
few weeks after the operation from accidental causes, they found, in place 
of the portion of the pancreas removed, a cyst, the size of a hen's egg, 
which had no communication with the duodenum, and was filled with a 
fluid which, like pancreatic juice, was coagulated by alcohol. In a 
second case operated upon in a similar manner, the weight of the animal 
increased in five and a half months twenty-five kilogrammes. When 
the animal was killed, only a trace of the pancreatic duct could be 
discovered. 

The portion of the gland left had undergone atrophy, and contained no 
ducts. The atrophied portion was eight to ten centimetres distant from 
the duodenum, and on section gave evidence of having undergone sclerosis. 
In five young dogs the pancreas was extirpated, leaving only that portion 
which lies upon the portal vein. All the animals remained well at the 
end of eight months. Three of the dogs were killed. In two of them 
the autopsy showed that the terminal extremity of the pancreatic duct 
remained as a blind pouch. The part of the gland left had become 
very much atrophied, and remained isolated from the duodenum. A 
glandular structure as large as a bean was found near the duodenum in 
both dogs; in one of them a duct connected this body with the bowel, 
while in the other no such connection could be traced. Taking it for 
granted that these small bodies were composed of pancreatic tissue, their 
weight being only about one-ninetieth part of the whole gland, the amount 
of secretion from them would not have been sufficient to emulsify the 
fats. In the third dog no trace of the pancreas could be found, and yet 
the animal's digestion and health appeared to be normal. The feces 
contained no undigested fat. From these and other experiments of the 
same kind, the authors came to the conclusion that the presence of the 
pancreatic juice is not essential in the process of digestion or absorption 
of fat in herbivorous, carnivorous, or omnivorous animals, or in birds. 

SchifF brought about complete suspension of the function of the 
pancreas in animals without removing any part of the organ by injecting 
the ducts of the gland with melted paraffin, which, at the temperature 
of the body, became a solid mass, completely obstructing the outlets for 
the secretion. Animals treated in this manner showed no signs of 
derangement of digestion, and were able to assimilate fat as well as 
healthy animals. 

The following experiments were made to ascertain the feasibility of 
complete extirpation of the pancreas, and the effects of such a procedure 



148 

upon digestion and assimilation. In all of the experiments the entire 
organ was removed. The hemorrhage was always profuse, and re- 
quired numerous catgut ligatures for its arrest. 

The larger vessels between the duodenum and pancreas were carefully 
isolated and removed with the gland, so that the intestine was deprived 
of its direct vascular supply over an area corresponding to the extent of 
the attachment of the pancreas. 

Experiment VI. — Brown dog, four and a half months old ; weight, 32 
pounds. The entire pancreas was extirpated, part of the dissection was made 
with Paquelin's cautery. Tenq;>erature on second day 104° F., on fifth day 
101£° F. (subnormal). On the fourth day diarrhoea set in : stools contained 
undigested food and free fat, and on the seventh day blood. On the ninth 
day the animal died. During the first few days the appetite remained unim- 
paired, but when the diarrhoea supervened food was taken only sparingly. 
At the autopsy it was ascertained that the animal had lost five pounds in 
weight. The abdominal cavity contained a considerable quantity of bloody 
serum, and the peritoneum presented evidences of recent diffuse peritonitis. 
The duodenum showed several dark spots on its convex surface, which might 
be taken for beginning gangrene. The pancreatic duct, traced from within 
the duodenum, was found closed at the point of section by a cicatrix upon 
the outer surface of the bowel. 

Whether in this case the diarrhoea resulted from the absence of the 
pancreatic juice or from the septic peritonitis, would be difficult to 
determine. The duodenum had been detached from its mesentery at 
least ten inches, and yet the gangrene, if any, after nine days was 
limited to a few circumscribed patches. 

Experiment VII. — Large black dog, four months old; weight, 48 pounds. 
Experience had proved that the separation of the pancreas and its vessels 
from the duodenum could be done more safely, and with less risk of hemor- 
rhage, by tearing the tissues instead of using the scissors or knife, employing 
the cutting instruments only when it was thought imprudent to use too much 
violence in separating strong connecting bands, which would not yield to 
gentle force. In this case twelve ligatures were required to arrest the hemor- 
rhage, in later experiments a much smaller number were found sufficient to 
arrest the bleeding, after I had learned to rely more freely on the tearing 
method in partial and complete extirpation of the pancreas. This dog never 
recovered fully from the operation and died on the fourth day, the tempera- 
ture having remained subnormal during the whole of this time. At the 
autopsy a perforation in the duodenum was found on the convex side about 
five inches below the pylorus; recent peritonitis, which was undoubtedly 
produced by extravasation consequent upon the perforation; gangrene of the 
bowel, circumscribed and limited to the seat of perforation, and a few other 
small spots on the convex surface of the bowel. Pancreatic duct at point of 
section not closed. 

In this case death was directly attributable to gangrene of the duode- 
num, caused by the extensive detachment of its mesenteric vascular 
supply. 

Experiment VIII. — Large adult cat. The operation occupied more than 
half an hour, and was attended by considerable hemorrhage from the deep 
attachments of the gastro-splenic end. The bleeding was finally arrested by 
ligating a number of vessels in the region of the spleen. The animal never 
rallied from the operation and died five hours later with symptoms of hemor- 



SENN, SURGERY OF THE PANCREAS, 



149 



rhage and shock combined. On opening the abdomen no blood was found 
in the peritoneal cavity, except a few flat coagula w r hich covered the denuded 
surface of the bowel, which extended seven inches in length. 

Experiment IX. — Adult female cat. The extirpation was again attended 
by free hemorrhage, and the animal died half an hour after the completion 
of the operation, with symptoms of hemorrhage and shock. 

Experiment X. — Adult black dog; weight, 33 pounds. Animal remained 
comparatively well for two days, when peritonitis supervened, which proved 
fatal on the fourth day after the operation. Wound closed ; peritoneal sur- 
faces separated with some difficulty. The abdominal cavity contained a quart 
of purulent fluid. At the same time, diffuse general peritonitis had given rise 
to extensive adhesions between the different abdominal organs. The duode- 
num appeared quite vascular and showed no signs of gangrene. 

Experiment XI. — Medium-sized adult cat. After the extirpation of the 
entire pancreas, the duodenum was found on measurement to have been de- 
nuded of its mesenteric attachment to the extent of seven inches. The 
venous oozing proved free, and could not be completely arrested during the 
time which it was deemed prudent to keep the abdominal organs exposed to 
the atmospheric air. The animal never rallied from the operation and died 
two hours later. On opening the abdominal cavity, a considerable quantity 
of fluid venous blood was found. In this case death was caused by uncon- 
trollable venous hemorrhage. 

Remarks. — It will be seen that of six animals subjected to complete 
extirpation of the pancreas, in all of them death occurred from a few 
hours to nine days after the operation. The cause of death was either 
the primary effects of the traumatism, hemorrhage, and shock, or from 
secondary pathological lesions traceable directly to the operation, as may 
be readily gleaned from the following table : 



No. 


Animal. 


Time of death. 


Cause of death. 


1 

2 
3 
4 
5 
6 


Dog, 

a 

Cat, 

cc 

Dog, 
Cat, 


Nine days, 
Four days, 
Five hours, 
Half an hour, 
Four days, 
Two hours, 


Peritonitis. 

Gangrene of duodenum. 

Hemorrhage and shock. 

a a a 

Purulent peritonitis. 
Hemorrhage. 



This table shows that the operation on cats proved more dangerous 
than on dogs, and of the three animals all died within five hours from 
the immediate effects of shock and hemorrhage. The three dogs died 
of peritonitis within from four to nine days. In one case the peri- 
tonitis was due to perforation, in the remaining two it was produced 
either through the wound or the pancreatic duct, which was found 
open in one of the cases. The complete extirpation of the pancreas 
necessitates such an extensive separation of the intestine from the 
mesentery, that this alone constitutes a great source of danger, as gan- 
grene may take place. It is important to repeat that in the two speci- 
mens which showed evidences of gangrene this was observed on the con- 
vex surface of the bowel, and in neither case did it involve the entire 
diameter of the intestine. It requires no explanation to show that in 



150 SENN, SURGERY OF THE PANCREAS. 

cases of this kind the collateral circulation is established first on the 
concave side, where the vascular supply is nearest and the force of the 
circulation most vigorous. In dogs and cats the pancreas is attached so 
intimately and extensively to the duodenum that complete extirpation 
is necessarily attended by profuse hemorrhage which often was found 
difficult, and in one instance impossible, to control. Ligation of some of 
the bleeding points was often found impossible, as any attempt in seizing 
the vessel necessarily grasped the muscular coat of the bowel, which it 
was thought to be dangerous to include in the ligature, as it might give 
rise to perforation. Steady pressure with a sponge wrung out of a hot, 
weak solution of corrosive sublimate w T as found to be the most reliable 
means in arresting troublesome oozing. None of these experiments was 
sufficiently successful to study the effect of complete extirpation of the 
pancreas upon digestion and assimilation. 

In a number of the autopsies, however, the lacteals contained a milky 
fluid, showing that at least a portion of the fatty food had been emulsi- 
fied by other secretions. As a final conclusion, I do not hesitate to 
affirm that in dogs and cats complete extirpation of the pancreas is 
always followed by death, either from the primary effect of the opera- 
tion, or the secondary consequences following it. 

Partial Extirpation of tlie Pancreas. 

Partial extirpation of the pancreas implies a less degree of trauma- 
tism, and consequently less danger of causing serious nutritive changes 
in adjacent organs than complete extirpation, and for these reasons it is 
less dangerous, in a strictly surgical sense. Physiologically, a partial 
extirpation of the organ may imply the same consequences as complete 
extirpation, as when the portion of gland removed embraces the com- 
mon duct or both principal ducts from each portion of the gland. 

Experiment XII. — Adult cat; weight, 6 } pounds. Pancreas drawn into 
the abdominal wound with the duodenum, and separated from the bowel to 
the extent of two inches, at a point corresponding to the middle portion of 
the gland. This section of the gland, which included the termination of the 
ducts, was excised with Paquelin's cautery; only one artery from the gastro- 
splenic end required ligature; ends of gland dropped into abdominal cavity. 
The temperature remained subnormal, 102° F., until the animal died, two 
days after the operation. At the autopsy, gangrene and perforation of the 
duodenum were found at a point corresponding to the site of resection. 

Experiment XIII. — Scotch terrier; weight, 25£ pounds. Ligated pan- 
creas at its middle, with catgut, and extirpated the gastro-splenic portion; 
eight ligatures were required to control the hemorrhage and about four inches of 
the duodenum were denuded of its mesentery. Second day after the operation 
the temperature was 100.4° F., which became normal (103° F.) on third day. 
During the first week the animal gained one pound in weight, showing that 
digestion was not disturbed by the absence of the pancreatic juice during this 
time. 

Three weeks after the operation the dog began to lose flesh ; the emaciation 
w T as progressive until the animal died of marasmus seventy-six days after the 
operation. During this time the appetite was not impaired, and at no time 



PANCKEAS. 151 

had diarrhoea been observed. The organs of the chest were found in a normal 
condition. The abdominal wound was firmly united. A few adhesions between 
the omentum and parietal peritoneum. No signs of peritonitis. The paren- 
chyma of the duodenal portion of the gland had disappeared completely by 
absorption, only the connective tissue and the duct, somewhat dilated, re- 
maining. The idea that degeneration and absorption of the parenchymatous 
structure of the gland were caused by local anamiia could not be enter- 
tained for a moment, as the connective tissue frame of the gland was freely 
supplied with numerous and large vessels. The portion of the duodenum 
stripped of its mesentery was repaired by a vascular strip of connective tissue, 
which restored the continuity of the mesenteric circulation. The common 
pancreatic duct was found obliterated at its point of entrance into the bowel, 
where it had been divided during the operation. 

Experiment XIV. — Adult cat; weight, 6 pounds. Extirpation of gastro- 
splenic and half of the duodenal portion of the pancreas, with separation ot 
duodenal mesentery to the same extent. The portion of the gland which 
remained was not ligated. The animal rallied from the immediate effects ot 
the operation, but died eighteen hours later in convulsions. At the autopsy the 
mucous membrane of the duodenum in the portion of the bowel which had 
been deprived of its direct vascular supply, presented a cyanosed appearance, 
but no distinct signs of gangrene. Abdominal cavity contained no fluid of 
any kind; peritoneum normal in appearance. Slight hemorrhage between 
peritoneum and transversalis fascia. 

Experiment XV. — Large adult dog; weight, 48 pounds. Extirpation of 
two-thirds of the pancreas with the common duct, leaving only a portion of 
the remote end of the gastro-splenic portion. The hemorrhage, which was pro- 
fuse, was carefully arrested, and the pancreas ligatecl before section. The first 
two days the temperature was subnormal, 101°-102.2° F. On the third day it 
became normal and remained so. The animal remained in perfect health for 
four weeks, when he commenced to lose flesh. Appetite voracious. No diar- 
rhoea, but stools contained undigested fat. Although the animal ate as much 
as four dogs of similar size, emaciation continued, and had become extreme 
when the dog was killed, 126 days after the operation. At the autopsy the 
abdominal incision was found adherent to the mesentery. The duodenum 
which had been stripped of its mesentery was found free, without a mesenteric 
attachment, but freely supplied with blood by two large vessels running 
through a band of connective tissue adherent to the bowel on the concave 
denuded side. The vessels were in communication with the adjacent intact 
mesenteric vessels, and served to complete the interrupted mesenteric circula- 
tion. The gastro-splenic portion of the gland which was left behind was 
found completely atrophied ; in its centre the duct could be seen dilated to 
the size of a leadpencil, and distended by a clear transparent fluid. The 
dilated duct had no communication with the bowel. 

Remarks. — As in all of these experiments the common ducts were 
removed with the excised portion of the pancreas, it left the animal 
physiologically in the same condition as after complete extirpation of 
the organ, as no pancreatic juice could find its way into the intestine. 
In Experiments XIII. and XV. the dogs lived for a sufficient length 
of time to determine the influence of the pancreatic secretion upon 
digestion and assimilation. In both of these animals the general 
health and nutrition remained unimpaired for four weeks, when emacia- 
tion, with fatty stools, followed, which resulted in death from marasmus 
in one, after seventy-six days, and reduced the second dog to a skeleton 
in one hundred and twenty-six days. As from the beginning no pan- 
creatic juice found its way into the intestine, it is difficult to account for 



152 SENN, SURGERY OF THE PANCREAS. 

the satisfactory condition of digestion, and the appearance of health of 
the animals for the first four weeks, followed by a progressive marasmus 
and increase of appetite. It is true that by the resection of the mesentery 
of the duodenum intestinal absorption was correspondingly diminished, 
but marasmus from this source ought to have manifested itself soon after 
the operation. It is now generally conceded that a healthy pancreas 
will absorb its own secretion in case there is any obstruction to prevent 
the normal escape of the pancreatic juice, and it may be that pancreatic 
juice entering the circulation in this manner may have some as yet un- 
explained action on digestion. Should this be the case, we might assume 
that the pancreatic tissue left behind continued to secrete until the 
parenchyma was incapacitated by degenerative changes to perform this 
function. 

All of the experiments made on the pancreas tend to prove that any 
portion of the gland when it becomes detached from the bowel, invariably 
undergoes degenerative changes, and that its parenchymatous structure 
disappears by absorption within a few weeks. In these cases we may 
safely assume that the remaining portion of the gland had been rendered 
physiologically incompetent during the first four weeks, the time during 
which the animals remained in a healthy condition. In Experiment XV. 
almost the entire duodenum had been suddenly deprived of its vascu- 
lar supply, and yet no gangrene occurred. The collateral circulation 
was established by the development of two large vessels in a band of 
cicatricial tissue along the concave surface of the bowel, which restored 
the interrupted circulation between the mesenteric vessels on each side 
of the resected portion of the mesentery. It is also important to mention 
that in both dogs the lacteals appeared empty at the autopsy. These 
experiments would then tend to prove that the pancreatic secretion is 
an important, if not essential, digestive fluid, and that in cases where no 
pancreatic juice can enter the intestine, or where the secretion is entirely 
suspended, digestion and assimilation become impaired, in all cases where 
the supposed vicarious action of other organs is inadequate to perform 
the functions of the extirpated or degenerated pancreas. 

Obliteration of the Pancreatic Duct by Elastic Constriction. 

A favorite method of studying the effect of exclusion of the pancreatic 
juice from the digestive tract has been ligation of the pancreatic duct. 
Against the reliability of these experiments it may be urged that in 
many animals the pancreas possesses more than one duct, and in some 
of them accessory ducts may be present, which in all probability would 
be overlooked in the operation, and thus complete exclusion would not 
be secured. In some of the smaller animals even the common duct is 
often found only after a prolonged and patient search, consequently any 
additional ducts or ductlets would be very likely to escape the attention 



SENN, SUKGERY OF THE PANCREAS. 153 

of the operator. Rabbits have, as a rule, only one duct, which enters 
the intestine eight to ten inches below the pyloric orifice of the stomach ; 
on this account the results obtained by experiments of ligating the duct 
have been most reliable when this animal was taken as an object for 
experimentation. 

Amozan and Vaillard (Pancreas du Lapin, Journ. de Med. de Bor- 
deaux, April 3, 1881) tied the pancreatic duct in rabbits, and studied 
subsequently the histological changes in the pancreas. Animals that 
survived the operation, and were killed after eight days, were consider- 
ably emaciated. On examining the pancreas it was found, as in the 
parotid gland, after tying its duct, that an excessive amount of connec- 
tive tissue had formed in and around the lobules, that the ducts were 
much dilated, and the epithelial lining partly thrown off; the epithelial 
cells had changed in position and form, and appeared atrophied. A care- 
ful microscopical examination of the specimen showed that ligation of the 
duct of Wirsung produced a gradual transformation of the pancreas into 
connective tissue ; the first effect is an enormous distention of the duct 
which extends to the most remote portions of the gland. The epithelial 
cells become detached, and with a colloid material present, lead to 
obstruction in the ducts. The gland cells, even as early as twenty-four 
hours after ligature, become translucent. After a few days the nuclei 
become swollen, and divide into two or three parts, which fill the inte- 
rior of the cell. After seven to nine days, the place of the cells is occu- 
pied by free nuclei and round and spindle-shaped cells, which are 
transformed into connective tissue. In the neighborhood of some of the 
veins collections of colorless corpuscles could be seen. The gland, on the 
whole, had undergone cirrhotic atrophy. 

According to Charcot and Gombault the same cirrhotic change is 
produced in the liver, by ligating the bile-ducts, while ligation of the 
ducts of the salivary glands and the ureters of the kidney produces only 
slight or no cirrhosis of those organs. 

Berard and Colin (Gaz. hebd., vi. 4, 1858) ligated the pancreatic duct 
in dogs which had fasted for several days, and then fed them well for 
twenty -four hours. The animals either showed no appetite, or, after 
eating, ejected the food from the stomach. If the animals were killed 
the lacteals were either only partially filled with a milky fluid, or, more 
generally, they were found empty. 

The authors then tied the pancreatic duct in sixteen dogs which had 
fasted four or five days, and immediately injected into the duodenum 
a quantity of oil and lukewarm water. The animals were killed three 
or four days afterward, and the lacteals were found to contain a white 
opaque chyle both in the mesentery and walls of the intestine. 

Cohnheim (Allgemeine Pathologie, Berlin, 1882) claims that digestion 
is performed in a remarkably satisfactory manner, even in case the pan- 



151 SENX, SURGERY OF THE PANCREAS. 

creatic juice is entirely absent, in the intestinal tract. He claims that 
the presence of fatty stools is the only symptom which can be positively 
brought in connection with a defective or total absence of pancreatic 
secretion. He asserts that in rabbits it is not difficult to ligate the pan- 
creatic duct, and that in cases where this is done, with the exception of 
a loss of appetite for a few days, the animals suffered no bad conse- 
quences, and in a few days were as well as before the operation. 

Langendorf ascertained by experiment that in pigeons a few days 
after obliteration of the ducts of the pancreas, the desire for food 
increased, but they emaciated progressively, because, as the author 
asserts, the carbohydrates were not digested. Cohnheim is of the opinion 
that in other animals the capacity of other organs to assume vicarious 
action is greater than in birds. Other digestive fluids perform the func- 
tion of the pancreas. The transformation of starch into glucose is accom- 
plished by the intestinal juice, and the emulsifying action of the pancreatic 
juice is assumed by the bile. The remnants of undigested peptones are 
removed by way of putrefaction induced by bacteria, which are always 
present in the intestinal tract. That the pancreas continues to secrete 
after ligation of the common duct has been demonstrated in Heidenhain's 
laboratory, where, thirty days after the duct had been ligated, normal 
pancreatic juice escaped through a canula introduced into the duct. The 
quantity was only slightly less than from a normal gland, and the dis- 
crepancy was readily explained, as some of the gland structures must 
have been destroyed by the increased pressure in the duct from the 
accumulated fluid. As the organ continues to secrete, and the space for 
accumulation is limited, the only logical conclusion which can be arrived 
at is that the secretion is removed by the bloodvessels and lymphatics in 
the gland. It has been shown by Kiihne that the introduction of pan- 
creatic juice into the circulation does not act deleteriously, as he injected 
one of its most active constituents —trypsin — directly into a vein without 
any immediate or remote ill effect upon the animal. As he detected this 
substance in the urine, it is reasonable to assume that the ferments of the 
pancreatic juice which have not been neutralized by deoxidation into 
the more innocuous zymogen are eliminated with the renal excretions. 

The following experiments were made, not so much to determine the 
effect of ligation of the pancreatic duct uj)on digestion, as with a distinct 
purpose of studying the effects, in the gland and its duct, which would 
follow sudden obstruction in the duct. Instead of resorting to direct 
ligation of the duct, the same object was accomplished with greater 
certainty and more ease by resorting to elastic constriction by using a 
rubber tube or band which was made to include the entire pancreas with 
or without its vessels. In every instance the elastic constriction produced 
complete division of the organ and its duct in a short time, and the 



SENN, SUEGEEY OF THE PANCREAS. 155 

elastic ligature was usually found encysted either at the site of applica- 
tion or a little distance from it. 

Experiment XVI. — Adult black dog; weight, 30 pounds. Pancreas and 
duodenum were drawn into the abdominal incision, and a fine rubber drainage 
tube was passed between the duodenum and the pancreas at the junction of 
the middle with the proximal third, and firmly tied. The knot was kept 
from unfastening by transfixion with a silk ligature. The vessels were 
included in the rubber ligature. The animal remained perfectly well after 
the operation and gained three and a half pounds in ten days. The dog was 
killed forty-nine days after the operation. On examination it was found that 
the abdominal wound had healed completely; slight adhesions between 
omentum and the lower portion of the cicatrix. The rubber ligature was 
found encysted at the junction of the middle with the proximal third (splenic 
end). The duodenal portion and the distal portion of the gastro-splenic end 
were unchanged, as the secretion could enter the intestine through the patent 
common duct. At the point where the ligature had been applied, the organ, 
with its duct, had been completely divided, the point of section being indi- 
cated by a contraction due to cicatrization. The duct in the isolated splenic 
portion was slightly dilated ; parenchymatous tissue in a state of degenera- 
tion ; well-marked sclerosis. 

Experiment XVIa. — White and yellow coach dog, four and a half months 
old ; weight, 32 pounds. In this case the rubber ligature was applied about 
the middle of the gland, including the artery, but not the vein. The animal 
remained in excellent health, and was killed ninety-eight days after the 
operation. At the autopsy the ligature was found encysted in a firm capsule 
about the middle of the gland. It had completely divided the pancreas and 
the duct of the splenic portion on the proximal side of the common duct. 
The duct in the isolated portion was considerably dilated throughout, and 
completely obliterated at the point of ligation. This portion of the gland had 
undergone parenchymatous degeneration and sclerosis, as the tissue was quite 
firm and grated on being cut with the knife. The portion of the gland remain- 
ing in communication with the intestine through the common duct presented 
a normal appearance. 

Experiment XVII. — Adult black dog; weight, 20 pounds; ligation of 
pancreas on the proximal side of the common duct, excluding the artery. 
The dog remained perfectly well after the operation, gained considerable 
flesh, and was killed in four weeks. The rubber ligature was encysted between 
the duodenum and pancreas. Complete division of pancreas and duct on the 
splenic side of the common duct. Slight dilatation of the duct in isolated 
portion, with the same tissue changes as in the preceding case. 

Experiment XVIII.— Adult black cat; weight, 5h pounds. The pancreas 
was detached from the duodenum to the extent of three-quarters of an inch, 
and the rubber ligature applied so as to exclude the artery. On the second 
day the temperature rose to 106° F., but the general condition of the animal 
was undisturbed. The fever soon subsided, and digestion and nutrition were 
at no time impaired. The cat was killed thirty-eight days after operation. 
The ligature was found encysted between the pancreas and duodenum on the 
distal side of the common duct. Complete division of the pancreas and ob- 
literation of the duct by a linear cicatrix. The detached mesentery was 
united with the bowel. The detached duodenal portion of gland had almost 
disappeared by absorption, only connective tissue and vessels being left to 
indicate the contour of the gland. 

Experiment XIX. — Adult white cat ; weight, 6| pounds. Detached pan- 
creas and vessels from duodenum to the extent of an inch and a half, and 
applied a rubber ligature about the middle of the gland, including the 
vessels. Next day the temperature was 105° F. ; later, normal. No disturb- 
ance of digestion or nutrition. The cat was killed eighty-five days after 
operation. The rubber ligature was encysted between duodenum and pancreas 
on distal side of the common duct. Complete section of pancreas and ob- 



156 SENN, SURGERY OF THE PANCREAS. 

literation of duct. The duodenal portion had almost completely disappeared 
by absorption; the connective tissue of the gland, the dilated ducts, and the 
abundant vascular supply, served to indicate the outlines of the atrophied 
portion. Mesentery of the duodenum was perfect. 

Experiment XX. — Young black cat ; weight, 2 pounds. Isolated pancreas 
to the extent of two inches from intestine, and included the detached portion 
between two silk ligatures, firmly tied. Temperature was high on second and 
sixth days. Animal died on sixth day. Abdominal wound was firmly united. 
On opening the abdominal cavity no effusion was found. No general perito- 
nitis. Abscess between duodenum and liver; ligated portion detached; gan- 
grenous ; ligatures not encysted. Abscess in communication with pancreas. 
Acute atrophy of the entire pancreas. No gangrene of duodenum. In this 
case the suppurative process started from the portion of pancreas which had 
been included between the ligatures. We shall find that when infection 
does not take place, even dead pancreatic tissue is amenable to absorption. 

Experiment XXI. — Old cat ; weight, 4 lbs. Detached gastro-splenic por- 
tion of the pancreas to the extent of an inch and a half from duodenum, and 
applied two rubber ligatures about one-half of an inch apart, including the 
vessels. On the following day the cat was quite ill, without any rise in tem- 
perature. For several days vomiting was the most prominent symptom. 
The animal died on the sixth day. Abdominal wound united; no peritonitis; 
no effusion. Pancreas adherent to transverse colon : on separating the adhe- 
sion a small cyst containing about three drachms of a clear, transparent fluid 
was ruptured. As this cyst corresponded to the place where the ligatures 
had been applied, it was undoubtedly a collection of pancreatic juice which 
had escaped from the divided duct, and around which a connective tissue 
wall had formed. The ligatures had cut through the organ and duct. The 
ends of the gland had retracted. Duodenum healthy. Mesenteric detachment 
not repaired. No suppuration anywhere. 

Experiment XXII. — Adult dog; weight, 39 lbs. Detached the pancreas, 
about its middle, from duodenum, to the extent of two inches, and applied 
two rubber ligatures, about one inch apart, including the vessels. On the 
following day, the dog appeared quite sick. Increase of temperature after 
sixth day ; no appetite, and rapid emaciation. On the ninth day, diarrhoea, 
which became later dysenteric in character. Died on the nineteenth day, 
having lost during this time six and a half pounds in weight. Abdominal 
wound completely united. No general peritonitis. Pancreas and duodenum 
adherent to liver. Portion of pancreas between ligatures gangrenous — con- 
tained in an abscess cavity. Ligatures detached and loose in abscess cavity. 

Experiment XXIII. — Adult black dog; weight, 20 lbs. Inclusion of two 
inches of pancreas and its vessels, after separation from duodenum, between 
two silk ligatures about the centre of the gland. The dog was very sick on 
second day, and thermometer showed an increase of temperature to 104.4° F., 
which continued with slight variations until the animal died on the sixth day. 
Wound completely united. Diffuse purulent peritonitis, and extensive ad- 
hesions. Ligated portion gangrenous and loose, with ligatures in abscess 
cavity between duodenum and pancreas. 

Experiment XXIV. — Adult gray cat; weight, 5| lbs. Isolated pancreas 
and vessels from duodenum to the extent of an inch and a half, and included 
this portion between two ligatures. Animal remained well for four days, when 
symptoms of peritonitis appeared. Died on tenth day. Wound nicely united. 
No peritoneal effusion. Localized peritonitis at site of operation. Ligatures 
and ligated section of pancreas loose in abscess between the duodenum and 
pancreas. Pancreatic veins thrombosed. Duct of splenic portion in direct 
communication with the abscess cavity. 

Experiment XXV. — Adult cat; weight, 6 pounds. Pancreas with its 
vessels detached from duodenum to the extent of two inches, and this portion 
included between two ligatures. On fifth day temperature 106° F., gradual 
decrease subsequently to normal. For a number of days during the febrile 
attack, complete loss of appetite. After this, appetite and nutrition were good. 
Killed twenty-eight days after operation. Portion of gland between ligatures 



157 

completely disappeared by absorption. Ligatures in close proximity and en- 
cysted in firm capsule. Duodenal end atrophied, in which the dilated duct 
was distinctly visible. Splenic end somewhat atrophied. 

Experiment XXVI. — Large Newfoundland dog; weight, 55 pounds. 
Eubber ligatures made to include one inch of the pancreas about its middle, 
with exclusion of its vessels. Slight fever on third day, subsequently no 
symptoms indicating disturbance of digestion or disease. Animal killed 
thirty-one days after operation. Intervening portion of pancreas disappeared 
by absorption. Ligatures encysted. Loss of substance replaced by bridge of 
connective tissue. Duodenal end atrophic with dilated duct. Gastro-splenic 
portion normal in appearance, and in direct communication with the intes- 
tine through the common pancreatic duct. 

Only two of the animals recovered after isolation and double ligation 
of the pancreas, a fact which shows the great danger of leaving pan- 
creatic tissue not supplied with blood in the abdominal cavity. We 
can only assume that the danger of infection is increased by leaving an 
exceedingly favorable culture substance for infective germs in the ab- 
domen. If the operation is perfectly aseptic, the dead pancreatic tissue 
remains aseptic and is removed in an exceedingly short time by ab- 
sorption. 

Experiment XXVII. — Large adult cat. Applied a single rubber ligature 
on distal side of the common pancreatic duct, excluding the artery and vein. 
No disturbance of digestion or nutrition, and temperature normal throughout. 
Animal, when killed twenty-eight days after operation, had grown fat. Only 
a few slight adhesions at site of ligation. Pancreas and duct were com- 
pletely divided and kept in contact by a linear cicatrix. Ligature was en- 
cysted between the duodenum and under surface of the liver. The gastro- 
splenic portion of the pancreas was normal in appearance, and connected 
with the common duct. The duodenal portion was atrophied; the duct 
slightly dilated. 

Experiment XXVIII. — Large Newfoundland dog. Ligation of the pan- 
creas and its vessels with a rubber ligature on the proximal side of the common 
duct. No fever, no disturbance of digestion or nutrition. Animal was killed 
ninety-one days after operation. On opening the abdominal cavity, the entire 
pancreas presented a normal appearance in size, shape, and consistence. 
Where the ligature was applied a narrow constriction was visible, which re- 
presented the point of section made by the ligature. Ligature was encysted 
in the cicatrix. On tracing the pancreatic duct from the interior of the in- 
testine, a probe could be passed along the duct of the duodenal portion. On 
following the duct of the splenic portion, the probe was arrested at the cica- 
trix, about a quarter of an inch from the wall of the intestine. The duct at 
this point was completely obliterated. As in all of the previous experiments 
the detached portion of the gland had invariably become the seat of degenera- 
tive changes and atrophy, I was at a loss to account for the normal appearance 
of the gastro-splenic portion of the gland in this instance. After a prolonged 
and careful search a minute opening was detected in the fold of the mucous 
membrane surrounding the outlet of the bile-duct, and by careful manipula- 
tion a delicate probe was passed along a canal which passed obliquely through 
the wall of the bowel, entered the pancreas on the splenic side of the ligature, 
and terminated in the large duct of the gastro-splenic portion. 

The explanation for the absence of atrophic changes had been found. An 
accessory duct had furnished an outlet for the secretion in the gastro-splenic 
portion, and had maintained the physiological connection between this portion 
of the gland and the duodenum after obliteration of the common duct of the 
gastro-splenic portion. It was the only instance where such a structure was 
detected, and the only specimen in which the normal structure of the detached 
portion of the gland was preserved after obliteration of the principal duct. 



158 SENN, SURGERY OF THE PANCREAS. 

Remarks. — These experiments illustrate the feasibility of ligation of 
either portion of the pancreas near the common duct as a surgical pro- 
cedure, and the regularity with which the pancreatic tissue is removed 
by degeneration and absorption in the detached portion of the gland. 
By physiological detachment I mean a permanent interruption to the 
escape of secretion by section or obliteration of the duct. 

After ligation of the duct or gland, secretion continues, and as the 
space for accumulation of the fluid is limited, a certain degree of pres- 
sure within the duct is established, as is evident from the uniformity 
with which the ducts throughout that portion of the gland were found 
dilated. In no instance, however, was anything observed which resem- 
bled a cyst. The dilatation was not limited to any particular portion of 
the duct, it always presented itself as a uniform ectasia of the entire duct. 
We can only explain the moderate dilatation by assuming that, as soon 
as a certain degree of pressure is reached, the pancreatic juice is removed 
by absorption by the vessels and lymphatics of the pancreas, and that a 
greater accumulation of fluid and distention of the duct could only occur 
when this function has become diminished or suspended by organic 
changes in the structures which are concerned in the removal of the 
secretions. The atrophic changes in the parenchyma of the detached 
portion of the gland have been ascribed to the pressure within the ducts 
upon the parenchyma cells — a sort of pressure atrophy. 

This supposition lacks proof, inasmuch as the pressure at any time 
could not have been considerable, and as the same atrophic changes have 
been observed in cases where no pressure could have existed, as in cases 
of external and internal pancreatic fistula, where the duct remains open 
until secretion ceases. The atrophy can also not be due to deficiency of 
blood supply, as it occurred regularly and as rapidly in cases where the 
blood supply remained unimpaired ; and in many of the specimens, illus- 
trating complete atrophy, the abundant vascular supply was distinctly 
observed and noted. I am unable to furnish a satisfactory explanation 
of the cause of this form of atrophy. All that I can say is, that in every 
instance in which complete physiological detachment had been produced 
by ligation, resection, crushing, or any other means, this result followed 
without exception. 

Practically this observation is of great importance, because it demon- 
strates that in operations upon the pancreas it is not essential or neces- 
sary to remove peripheral portions of the gland, for fear that if any of 
the parenchymatous structure should remain a retention cyst would 
follow. In partial resections for injury or disease it would be advisable 
to ligate the peripheral portion, and permit it to remain, as it would 
lessen the danger by the infliction of less traumatism, and we can con- 
fidently expect that it will be removed in a short time by absorption. 

These experiments settle definitely an important pathological question. 



159 

It has been claimed by all writers that cysts of the pancreas are produced 
by obstruction of the common duct. In most of the specimens which 
have been examined, it is distinctly stated that the obstruction was not 
complete, as, for instance, in cases of impaction of pancreatic calculi 
when found in connection with cysts. In all of these experiments 
obstruction of the duct was sudden and complete by the elastic constric- 
tion, and subsequently permanent by the formation of a cicatrix between 
the divided ends of the duct. 

In none of the specimens, where life was sufficiently prolonged, did the 
process of obliteration fail to take place, and yet in none of them was 
even an attempt at the formation of a cyst observed. 

The experiments with the double ligature teach the importance of 
removing such portions of the pancreas as are not supplied with blood- 
vessels, rather than trust to the doubtful expedient of leaving them to 
be removed by absorption, as dead pancreatic tissue is an exceedingly 
putrescible substance, and furnishes the most favorable conditions for 
the growth and increase of septic germs. 

External Pancreatic Fistula. 

The formation of a permanent pancreatic fistula has always consti- 
tuted one of the most difficult tasks in experimental physiology. Bernard 
(Legons de physiol. expcr. appliqnee a la medicine, t. ii., Paris, 1855), 
after many fruitless attempts, declared that it was impossible to establish 
a permanent pancreatic fistula, for the reason that the canula in- 
variably fell out after a few days, after which the duct again conveyed 
its contents into the duodenum. He found, also, that the pancreatic 
juice which flowed from the fistula remained normal only for twelve or 
sixteen hours, after which time it became thinner, and did not coagulate 
on the application of heat. Neither did it possess any longer the property 
of decomposing fat into glycerine and fatty acids. This change in the 
pancreatic juice always appeared as soon as inflammation was noticed 
about the seat of operation. 

In horses and cattle this condition appeared so early, that it was found 
impossible to obtain pure pancreatic juice from a fistula. 

The intermittent action of the pancreas was well illustrated in animals 
when a fistula has been established, active secretion only taking place 
during digestion. He ascertained that in medium-sized dogs, in an 
hour, not more than five or six grammes of juice could be obtained. 
Ether injected into the stomach increased the secretion, while vomiting 
suspended the flow of fluid, but not its secretion, since just after the act 
it was poured out in so much greater quantities. Pressure on the abdo- 
men and the respiratory movement of the chest accelerated the flow from 
the fistula. 



160 SENN, SURGERY OF THE PANCREAS. 

The following experiments were made for the distinct purpose of 
studying the functional activity of a detached portion of the pancreas, 
consequently a different method of operating had to be devised. 
Having satisfied myself that physiological detachment of a portion ot 
the pancreas by section, resection, or ligation always results in degen- 
eration of the parenchyma, and atrophy of the detached portion, I deter- 
mined to study this subject more thoroughly by interrupting all ana- 
tomical continuity between the detached and the principal portion of the 
gland. An external pancreatic fistula was established by bringing the 
pancreas with the duodenum into the wound, ligating the pancreas 
usually below the common duct, dividing the gland and its vessels com- 
pletely on the distal side of the ligature, arresting carefully the hemor- 
rhage from the cut surface without interfering with the principal duct, 
detaching the distal, or duodenal portion sufficiently from the bowel, so 
as to bring the cut surface a little above the level of the outer surface 
of the wound, where it was fixed with four catgut sutures to the margin 
of the wound. The remaining portion of the wound was closed in the 
usual manner. This method secured a permanent pancreatic fistula, the 
outflow from which would indicate the amount of secretion from the 
detached portion of the gland. 

Experiment XXIX. — Young dog; weight, 30 pounds. Ligated pancreas 
at junction of middle with distal portion, section of gland immediately below 
ligature, separation of detached portion from duodenum to the extent of two 
inches, implantation of free end into the lower angle of the abdominal inci- 
sion with four catgut sutures. During the second day, slight rise in the tem- 
perature. During the first day the dog refused to eat, and no pancreatic juice 
was seen to escape from the cut surface of the gland. The second day the 
secretion was copious, resembling normal pancreatic juice. The discharge 
was intermittent, most copious a few hours after eating, and entirely absent 
when the animal fasted. At the end of the first week, the secretion became 
less in quantity, and gradually continued to decrease until it ceased entirely 
on the twenty-first day. The portion of the pancreas included in the wound, 
became smaller from day to day, and appeared to have disappeared almost 
entirely when the secretion ceased, leaving at this place an irregular de- 
rjressed cicatrix, with no tendency to hernial protrusion. 

The animal remained in perfect health and was killed seventy days after 
operation. At the autopsy, the cut end of the atrophic duodenal portion of 
the pancreas was found adherent to, and incorporated in the firm cicatrix of 
the abdominal wound. The parenchyma in the detached portion of the gland 
had disappeared completely ; in the centre of this portion the principal duct 
could be seen dilated to the size of a lead-pencil, and it contained a clear, trans- 
parent fluid. The duct could be traced to the peripheral extremity of the 
gland in one direction, and into the cicatrix of the abdominal wound in the 
other. 

The atrophic portion of the gland was freely supplied with bloodvessels. . 
The duct was widest near the cicatrix, and gradually tapered toward the end 
of the gland. The cut proximal end had become adherent to the duodenum. 
A probe could be passed from the duodenal end of the common pancreatic 
duct along the entire distance of the splenic portion, the point of section had 
evidently been made on the peripheral side of the common duct, through the 
duodenal portion of the gland. 

Experiment XXX. — Adult cat; weight, 5 pounds. In this case the 
gland was divided near the middle. The duodenal portion was detached 



PANCREAS. 161 

from the intestine to the extent of two inches, and sewed into the lower angle 
of the incision. Second day temperature, 105.8° F. 

The animal took but little food, and only a very small amount of secretion 
was observed to escape from the duct on the cut surface of the gland. The 
cat died on the third day after the temperature had shown an increase to 
106° F. At the autopsy it was shown that death had resulted from purulent 
peritonitis, and croupous pneumonia of right lung. No gangrene of duo- 
denum or pancreas. 

Experiment XXXI. — Adult cat; weight, 5f pounds. Operation same as 
before. The animal was quite ill for three days ; at the end of this time the 
temperature was 104.8° F.; took but little nourishment. From this time im- 
provement took place, and finally complete recovery. 

Escape of pancreatic juice first observed on second day, gradually increased 
for three days, when it began to diminish and ceased completely on the seven- 
teenth day, when the wound closed completely, showing no tendency to ven- 
tral hernia. Unfortunately the animal was lost on the forty-eighth day. 

Experiment XXXII. — Black shepherd dog ; weight, 43i pounds. Liga- 
tion of pancreas about its middle, double ligation of pancreatico-duodenal 
artery, division of gland, application of four ligatures to arrest hemorrhage 
from the distal portion of the gland, detachment of duodenal end to the extent 
of two inches from intestine and fixation of free end into the lower angle of 
the incision by four catgut sutures. No untoward symptoms after operation. 
Free escape of pancreatic juice at the end of the second day, which continued 
quite profuse for ten days during digestion, when it began to diminish, and 
ceased entirely on the twenty-fifth day after the operation. During the first 
six days the animal lost four pounds in weight, after this time digestion and 
nutrition perfect. The dog was killed forty-six days after operation. Post- 
mortem appearance almost identical with that in Experiment XXIX., only 
that the duodenum was found adherent to the under surface of the liver. The 
vascularity of the atrophic duodenal end was particularly well marked. 

Remarks. — These experiments have demonstrated conclusively that 
when a portion of the pancreas is detached by complete section, secretion 
continues until, by degeneration and absorption, the parenchyma of the 
gland has disappeared. The degeneration evidently commences at the 
end of eight to twelve days, and progresses rapidly and continuously 
until the end of twenty to twenty-seven days, when all of the secreting 
structures have lost their physiological function, as indicated by a per- 
manent cessation of the flow of pancreatic juice. The existence of* dis- 
tention of the principal duct in these cases can only be explained by 
assuming that it occurs after closure of the fistula has taken place by an 
accumulation of secretion from the lining of the duct, or that the dilata- 
tion is caused by traction upon the outer surface of the duct by the con- 
nective tissue framework of the gland, or the contraction incident to 
interstitial connective tissue proliferation. That the atrophy in the part 
of the organ which had been detached from its connections with the 
intestine was not due to a traumatic interstitial pancreatitis is proved by 
the normal appearance and structure of the remaining portion of the 
gland which had retained its anatomical and physiological relations 
to the intestine. I am, therefore, again supported in the assertion that 
physiological detachment of any portion of the pancreas is invariably 
followed by degeneration and complete atrophy, consequently also by 
complete cessation of functional activity. 

no. clxxxiii. — july, 1886 11 



162 SENN, SURGERY OF THE PANCREAS. 

Internal Pancreatic Fistula. 

It is a well-known fact that when pancreatic juice is brought in con- 
tact with the skin it produces irritation, an effect which has been attrib- 
uted to its digestive qualities. In all the animals where an external 
pancreatic fistula was established, the skin appeared sore and macerated 
as far as it had been kept moist with the pancreatic juice. 

Clinical observation has shown that in nearly all cases where a cyst 
of the pancreas was treated by the formation of a pancreatic fistula the 
skin around the fistula remained in an eczematous condition so long as 
the fistula continued to discharge fluid. Taking these facts into con- 
sideration, we should naturally anticipate that when pancreatic juice is 
brought in contact with the peritoneum it would produce a destructive 
effect upon it by its digestive properties, or it might be even followed by 
diffuse peritonitis. 

In opposition to this reasoning, Bernard informs us that none of his 
animals died when he had made a pancreatic fistula, and as in these 
cases extravasation of pancreatic juice into the peritoneal cavity was 
almost inevitable, it would appear that its effects here are not so disas- 
trous as when it acts upon the skin. Concerning this point, Heidenhain 
remarks: " The animals do not suffer from this circumstance, as the duct 
is regenerated in spite of the wounded surface being bathed in the secre- 
tion. Nevertheless, it is difficult to explain this. Why do not the 
wounded and suppurating tissues undergo digestion by the pancreatic 
juice? The efficacy of the albumen ferment is destroyed in some way, 
I j)resume, probably by being converted into zymogen, the living tissues 
having the same effect on the juice as Podolinski observed, by treating 
the pancreatic juice with powdered zinc or yeast ferment." As pan- 
creatic juice, when brought in contact with the atmospheric air, may 
undergo rapid changes, and thus render it abnormal, experiments made 
with it by injecting it into the peritoneal cavity, would not represent the 
action of normal pancreatic juice upon the peritoneum, hence the results 
obtained would not represent the effects of normal secretion. To deter- 
mine the effect of normal pancreatic juice on the peritoneum, I resorted 
to the formation of an internal pancreatic fistula, so as to bring the perito- 
neum in contact with the normal pancreatic secretion as it escapes from 
the cut surface of the gland. My experiments with external pancreatic 
fistula had taught me that the isolated portion of the gland continued to 
secrete for seventeen to twenty-six days ; hence, I was convinced that if 
I could establish the same conditions within the peritoneal cavity, I 
would secure an intermittent flow of normal pancreatic juice into the 
peritoneal cavity for the same length of time. The operation was per- 
formed in j)recisely the same manner as for external fistula, except that 



SENN, SURGERY OF THE PANCREAS. 163 

the cut end of the duodenal portion was detached from the duodenum, 
turned downward, and dropped into the peritoneal cavity. 

Experiment XXXIII. — Young dog; weight, 31? pounds. Section of 
pancreas near middle, detached duodenal end from bowel to the extent of 
three inches, turned it downward and closed the abdominal wound completely. 
Second day, temperature 106° F. ; slight tympanitis ; dog appeared quite ill 
for a number of days, and temperature remained above normal for a week, 
after which, though the animal remained in good condition until killed, 
seventy-six days after the operation, the autopsy showed evidences of a 
former local peritonitis at the site of operation ; duodenal or detached end of 
pancreas completely atrophied, its ducts dilated, closed, and adherent to 
duodenum. Splenic portion normal in size and appearance ; cut end adherent 
to duodenum ; common duct pervious. 

Experiment XXXIV. — Adult dog ; weight, 21 pounds. Detached pan- 
creas from its middle toward distal side to the extent of five inches. Divided 
the pancreas with Paquelin's cautery, between two compression forceps ; used 
no ligatures. Turned end of lower portion downward, and closed the abdominal 
incision. Animal died on third day, with symptoms of peritonitis. No rise 
in temperature. Post-mortem examination showed evidences of diffuse puru- 
lent peritonitis; no hemorrhage; no sign of gangrene of duodenum. 

Experiment XXXV. — Adult dog ; weight, 37 pounds. Ligated pancreas 
on distal side of common duct. Divided the gland transversely just below 
ligature, tied vessels with catgut, detached duodenal portion from intestine to 
the extent of three inches, turned the free end downward and closed the 
abdominal incision. Temperature remained normal, but the animal was 
reported sick for five days, when recovery set in, and the dog remained in good 
health as long as he was under observation — thirty-two days, when he ran away. 

Experiment XXXVI. — Adult cat ; weight, 5| pounds. Applied ligature 
below common pancreatic duct, and divided the gland on distal side of liga- 
ture, detached duodenal portion from intestine to the extent of two inches, 
turned the free end downward, and closed the abdominal wound. The animal 
remained well after the operation, and was in good condition when killed 
eighty-three days after the operation. Great omentum adherent to lower 
border of liver ; mesentery adherent to duodenum ; duodenal portion of gland 
completely atrophied ; cut extremity of splenic portion adherent to duodenum 
by a firm cicatrix just below the entrance of the common duct into the intes- 
tine. This portion of the gland normal in size and appearance. Atrophied 
portion abundantly supplied with bloodvessels. 

Experiment XXXVIL— Adult cat; weight, 5J pounds. Pancreas was 
ligated just below the common duct, transverse section of the pancreas below 
ligature, detached the peripheral portion to the extent of an inch and a half, 
turned the free end downward and closed the abdominal incision. Death on 
third day. No hemorrhage into the abdominal cavity ; diffuse purulent peri- 
tonitis ; adhesions between the duodenum, liver, and greater omentum. 

Experiment XXXVIII. — Young cat, same operation as in Experiment 
XXXVII. No serious symptoms were observed after the operation. About 
two weeks later progressive emaciation until the animal died forty-two days 
after operation. At the post-mortem, an extensive abscess was found under- 
neath the skin over the sacrum. Some evidences of previous peritonitis, but no 
effusion or suppuration. Duodenal or detached portion quite vascular, but in 
a condition of advanced atrophy. Splenic portion was normal in size and ap- 
pearance, but cut end firmly adherent to duodenum below the entrance of the 
common duct. 

Experiment XXXIX. — Young cat. Operation the same, followed by no 
serious symptoms and no rise in temperature. Animal was killed seventy days 
after the operation. At the autopsy, the lower border of liver was found ad- 
herent to the cicatrix of the abdominal wound. Duodenal portion was com- 
pletely atrophied. At the point where the duodenum was denuded of its 
mesentery, the bowel had become acutely flexed by cicatricial contraction 
which approximated the raw surfaces. The same cicatrix connected the 
atrophied and intact portion of the pancreas. 



164 SENN, SURGERY OF THE PANCREAS. 

Experiment XL. — Adult cat ; pancreas detached from duodenum to the 
extent of an inch and a half, otherwise operation same as in preceding cases. 
Rise in temperature on fourth and seventh day, otherwise the animal was in 
good condition. Killed forty-two days after the operation. Animal was well 
nourished. Great omentum adherent to cicatrix of wound. 

At the point where the gland was detached from the duodenum, the bowel 
doubled upon itself acutely, the raw mesenteric surfaces in direct contact. 
The connective tissue remnant of duodenal portion is incorporated in this 
cicatrix but can be readily identified. Cut surface of splenic end was firmly 
adherent to the duodenum below the entrance of the common duct ; presents 
normal appearance in size, consistency, and shape. 

Experiment XLI. — Young cat. Operation the same as in preceding case. 
Temperature on fifth day, 105.5° F. Animal was killed on seventh day, 
wound not completely healed. Abscess on concave side of the duodenum. 
No peritoneal effusion or signs of general peritonitis. 

Experiment XLII. — Adult dog ; weight, 13 pounds. Operation same as 
before, mesenteric denudation of duodenum two inches. From second to 
eighth day slight rise in temperature. Animal in excellent condition 
when killed thirty-five days after operation. Small ventral hernia. A num- 
ber of adhesions at site of operation. Mesenteric circulation at point of de- 
tachment restored by a plexus of new vessels, contained in a narrow band of 
cicatricial tissue. Duodenal portion almost completely absorbed, only a few 
scattered imperfect lobules visible. Splenic end normal and in communica- 
tion with duodenum through common duct. 

Experiment XLIII. — Adult dog ; weight, 15 pounds. Operation same as 
in preceding experiment. No disturbance of digestion or nutrition, and no 
rise in temperature. Animal was in good condition when killed thirty-five 
days after operation. Duodenal portion indurated and contracted into a 
hard string which contains a dilated duct. Liver adherent to diaphragm. 
Duodenum without a proper mesentery over a space of several inches, vas- 
cular supply furnished by new vessels passing along the surface of the bowel 
on the concave side. Examination shows that ligature had been applied on 
splenic side of duct, and that the section had probably been made near or 
through the common duct, as the splenic portion was also in a state of ad- 
vanced atrophy and not in communication with the bowel. The duodenal 
portion was in a state of extreme atrophy, much shortened, and firmly adher- 
ent to the bowel. Just below point of operation, a small encapsulated abscess 
was found on the convex side of the bowel. 

In this case no pancreatic juice could gain entrance into the bowel, and yet 
digestion and nutrition appeared to be unimpaired. 



No. 


Animal. 


Time of death. 


Cause of death. 


1 


Dog, 


76 days, 


Purulent peritonitis. 


9 


a 


3 " 


Killed. 


3 


a 


Living, 


Ran awav 3 2d dav. 


4 


Cat, 


83 days, 


Killed. 


5 


" 


3 " 


Purulent peritonitis. 


6 


a 


42 " 


Abscess in sacral region. 


7 




70 " 


Killed. 


8 


" 


42 " 


" 


9 


" 


7 " 


" 


10 


Dog, 


35 " 


a 


11 




35 " 


a 



Remarks. — As in cases of external pancreatic fistula the secretions 
amounted often to more than four ounces a day, we have every reason 
to believe that the same quantity was secreted and discharged into the 



SENN, SURGERY OF THE PANCREAS. 165 

peritoneal cavity in the cases in which an internal pancreatic fistula was 
established. The effect, if any, of the pancreatic juice upon the peri- 
toneum can be seen best by an examination of the preceding table. 

In only two of the eleven experiments was death caused by purulent 
peritonitis. In one a circumscribed abscess was found in the concavity 
of the duodenum, and in one animal a small abscess, with thick walls, 
was found on the convex surface of the duodenum, which did not give 
rise to any symptoms during life. One of the cats died from the conse- 
quences of a large abscess over the sacrum forty-two days after the 
operation. The post-mortem appearances in the abdomen pointed to 
only a very circumscribed peritonitis at the seat of operation. As the 
mortality, after the formation of an internal pancreatic fistula, did not 
exceed the death-rate of any other form of operation upon the pancreas, 
we are justified in the assertion that normal pancreatic juice, when 
brought in contact with the peritoneum, does not produce peritonitis. 

Another question which presents itself, is this : What becomes of 
the pancreatic juice in the peritoneal cavity ? No mention is made in 
the autopsy records of these cases, of the presence of any kind of effusion 
in the peritoneal cavity, except in the two cases where death resulted from 
purulent peritonitis, when the abdomen contained a considerable quantity 
of a sero-purulent fluid thrown out by the inflamed serous membrane. 
From these evidences we can only arrive at the legitimate and logical 
conclusion that normal pancreatic juice is promptly and rapidly removed 
by absorption when brought in contact with the peritoneum. The uni- 
formity with which the detached portion of the pancreas was found 
atrophied, only corroborates the statements previously made when we 
considered the same question in connection with external pancreatic 
fistula. Another incidental observation of considerable importance was 
made concerning the danger of gangrene of the duodenum in case the 
mesentery is detached to any considerable extent. 

In all of these experiments the duodenum was denuded of its mesen- 
tery, and consequently deprived of its direct vascular supply to the 
extent of from one to three inches, and yet in no case was the duodenum 
found gangrenous. As in other experiments upon the pancreas, the 
duodenum showed a marked immunity against gangrene from interruption 
of its vascular supply. The last experiment is of great importance, as 
it illustrates that digestion may remain unimpaired even if no pancreatic 
juice is produced, or in the event of its secretion not gaining entrance 
into the intestine on account of complete and permanent obliteration of 
the common or principal pancreatic ducts. The ligation experiments, 
as well as the internal pancreatic fistula, also corroborate the statement 
made by some authors, that the introduction into the circulation of nor- 
mal pancreatic juice is innocuous, and that this abnormal supply is 
'tolerated for two weeks or more without any appreciable ill consequences. 

(To be continued.) 



166 RAYMOND, ELEPHANTIASIS ARABUM. 

ELEPHANTIASIS ARABUM OF THE LABIA MAJORA. 

A CASE OF SUCCESSFUL OPERATION BY EXCISION. 

By Henry I. Raymond, A.M., M.D., 

ASSISTANT SX T RGEON UNITED STATES ARMY. 

Ellen, a full-blooded Indian, set. twenty-eight, complexion that of a 
mulatto, hair black, physical condition good. She has lived all her life 
on the malarious banks of the Klamath, in California. It has been her 
habit since childhood to bathe and swim in the Klamath River, and her 
dietary has consisted largely of the fish caught in those waters. Un- 
married, but became pregnant by a half-breed, and was delivered of a 
living child at full term three months ago. A venereal taint, although 
probable from the presence of two large condylomatous growths near 
the anus, is denied. A tumor of her genital lips, from the size of a 
walnut to that of a closed fist, has existed from birth. Though possibly 
congenital, the disease was not hereditary. The dimensions of the 
labial tumor at the time the patient conceived were about those of the 
double-clenched fists, but as the foetus grew the pudendal swelling in- 
creased pari passu, so that at the termination of pregnancy the hyper- 
trophic growth had attained nearly its present dimensions. Has occasional 
chills, and has had oue since she came into the valley for surgical treat- 
ment. The cold stage lasts about half an hour, and then follow the hot 
and sweating stages. During the malarial paroxysms the tumor smarts 
and burns, and feels hot and tense, until relief comes in the sweating stage. 

On December 4, 1885, 1 saw the patient for the first time and found a 
pendulous mass of solid but elastic consistency hanging from the puden- 
dum, suspended by a strong pedicle, of horseshoe shape. The skin of the 
pedicle was slightly thickened, but not nodular ; it was not adherent to 
the subjacent tissue, or abnormal in color. It was the natural skin of the 
abdomen drawn by virtue of its elasticity much below the pubic sym- 
jmysis ; the pubic growth of hair was seated upon the body of the tumor. 
The skin of the tumor proper was thickened and rugose and in places 
nodular, and adherent throughout to the parts beneath. It was markedly 
pigmented. No increased sensitiveness in the tumor. A deep sulcus 
(three inches) extended along its posterior aspect from the anterior com- 
missure of the vulva downward. No particularly offensive odor came 
from the parts. The urine on being voided ran down the sulcus and 
caused more or less irritation and burning. The cumbersomeness of this 
cutis pendula greatly impeded locomotion ; when this act was performed 
the growth was swung between the thighs posteriorly. Its attachments 
would not permit it to be carried upward over the abdomen. The largest 
circumference of the outgrowth was the horizontal, being thirty inches, 
the antero-posterior twenty-four inches, the latero-lateral twenty-two 
inches, shortest circumference of pedicle, eighteen inches. 1 

Opp:ration. — On the 2d day of January, 1886, the patient was 
placed upon the operating table and the tumor compressed by an elastic 
bandage to drain it of its blood. To our astonishment the pedicle became 
more solid and largely increased in bulk, while the fundus yielded to the 
palpating fingers the sensation of elastic fluctuation. The bandage was 
removed at once and the growth allowed to hang pendent in the hope that 
it would revert to its original shape, as the increased bulk of the pedicle 

1 The growth was forwarded to the Surgeon-General, U. S. Army, for the National Medical Museum. 



RAYMOND, ELEPHANTIASIS ARABUM. 



167 



was objectionable. The shape the tumor assumed under compression 
found its explanation later in the histology of the morbid growth ; this 
latter was made up largely of fat and cellular spaces filled with albu- 
minous fluid. My only medical assistant was Dr. William Michel, phy- 
sician to the Hoopa Valley Indian Reservation, other assistants being six 
non-commissioned officers of Co. G., 8th U. S. Infantry. 

Every precaution was taken to guard against excessive hemorrhage 
and shock. Actual cautery irons were at hand to sear the tissues if 
need be, after staying the flow of blood by Esmarch's rubber tubing. 
I placed my chief reliance for the prevention of loss of blood, however, 

Fro. 1. 




Front view of tumor. 



upon a cord tourniquet made by an Indian out of some peculiar fibre 
stronger than any white man's thread, and applied after the manner of 
Fayrer's whip-cord tourniquet, viz., with a ring slipped over a loop of 
the cord to keep the cords together when traction was made. The ends 
of the cord, attached to wooden handles, were intrusted to the care of two 
assistants. The device is the same as that used by stockmen in altering 
their cattle and stallions. 

The patient having been put under ether, an incision through the skin 
nearly two feet in length was made around the pedicle from one labium 
to the other, sparing the sound skin, which was then reflected and the 
cord tourniquet adjusted. To prevent any possibility of its slipping or 
of allowing the pedicle to retract after excision, two long upholsterer's 



168 



RAYMOND, ELEPHANTIASIS ARABUM. 



needles were made to transfix the pedicle on a plane just anterior to the 
tourniquet and posterior to the contemplated excision. The tumor was 
removed by a few strokes of the knife. On loosening the tourniquet 
trifling hemorrhage followed, chiefly venous. This was arrested by hot 
water and compression, so that not a single ligature was applied. 

The operation lasted thirty-five minutes. Sufficient sound skin was 
saved to cover with flaps nearly the entire raw surface of the amputa- 
tion cut. Through drainage was instituted. Healing was accomplished 
in about two weeks, except over an area two inches square, which was- 
left to cicatrize. The temperature ranged between 99° F. and 101° F. 

Fig. 2. 




Back view of tumor. 



except on the fifth day when it touched 103° F., owing to defective drain- 
age. On the seventh day the temperature fell to normal, and thereafter 
intermitted each morning, but did not vary much from the norm. 

Several interesting features in the clinical history of Arabian elephan- 
tiasis are illustrated by the foregoing case: (1) The predilection of ele- 
phantoid disease for the dark races. (2) Its etiological relations to 
malaria and other climatic influences. (3) The unimportant role that 
heredity appears to play as a predisposing cause. (4) The impetus com- 
municated to the growth of the morbid mass by the advent of pregnancy. 
(5) The foetus was carried to full term, and delivery was not impeded by 
the immensely hypertrophied labia, as the parturient canal and outlet 
were not compromised in their distensibility and calibre. 

Fort Gaston, Hoopa Vallev, California. 



REVIEWS. 



Recent Brain Surgery. 

1. Transactions of the American Surgical Association. Volume 
III. Edited by J. Ewing Mears, M.D. 8vo. pp. xxxv. 396. Phila- 
delphia: P. Blakiston's Son & Co. London: Cassell & Co. Limited. 

2. The Field and Limitation of the Operative Surgery of the 
Human Brain. By John B. Roberts, A.M., M.D., Prof, of Anatomy 
and Surgery in Philadelphia Polyclinic. 8vo. pp. 80. Philadelphia : 
P. Blakiston's Son & Co., 1885. 

3. Case of Cerebral Tumor. By A. Hughes Bennett, M.D., F.R.C.P. 
The Surgical Treatment, by Rickman J. Godlee, M.S., F.R.C.S. From 
Vol. LX VIII. of the Medico- Chimrgical Transactions. London, 8vo. pp. 33. 

Pending an examination of the larger volume above mentioned, we 
would direct attention to its opening paper, which stands second in our 
caption, and the account of an actual experience in brain surgery, which 
we have named last. We do this with the less hesitation, on account 
both of the importance of the subject and from the excellence of the 
work which Dr. Roberts has put into his paper. Excellent from its 
thoroughness and its orderly arrangement, even if we may be unwilling 
to follow T him at all lengths in the revolutionary teachings into which 
his enthusiasm has led him. 

It is not very long since when, under the reaction which followed the 
free use of the trepan by surgeons a century ago, there was a great in- 
disposition to interfere with brain cases, and the expectant method, aided 
by more or less wisely conceived general treatment was the principal 
reliance of most conservative surgeons. Indeed, it is not many years 
since the trephine w T as a but little used instrument, and when, though its 
value was theoretically admitted, its application was very rare, and it 
was allowed to repose for long periods in the case which contained it. 
But again the pendulum swings, and this brochure of Dr. Roberts sets 
forth the widespread change which has come into the minds of many 
surgeons, while he lays down rules and principles of treatment which, 
if sustained by experience and general observation, will make the opera- 
tion of trephining a most common one. As we have hinted, the enthu- 
siasm of Dr. Roberts has led him very far, and some of his statements 
brought upon him much criticism at the Association when they were first 
promulgated ; but new measures need enthusiastic support, and we believe 
the very positiveness of his expressions will lead many to make at least 
partial trial of the steps he recommends, and result in a modified adoption 
of some of his views. 

The improved results obtained by antiseptic surgery, and the advances 
made in cerebral localization, have been factors which inevitably led to 
bolder and more extreme measures in dealing with brain injuries, from 
the comparatively greater safety attending operations, and the much 
greater accuracy attainable in locating the precise point of injury. How 
accurately the seat of disease may be localized is well shown by the 
pamphlet named last at the head of this review. This pamphlet tells of 



170 REVIEWS. 

a patient who suffered intensely from neuralgic pains, in addition to the 
distressing symptoms of advancing epilepsy, apparently dependent upon 
an old cranial injury from a falling tree. By an application of the prin- 
ciples of cerebral localization, the diagnosis was made that there was 
an encephalic growth of limited size at the middle part of the fissure of 
Rolando. The severity of the symptoms warranting interference, a tre- 
phine was three times applied, a triangular portion of the skull being 
thereby removed. After incising the dura mater, which presented 
nothing peculiar beyond somewhat excessive bulging, it was deemed 
wise to make an incision into the exposed cerebral convolution, and at a 
depth of from one-eighth to one-quarter of an inch a gliomatous tumor 
was exposed and successfully removed. 

We say successfully, for the reason that the patient survived from 
November 25th to December 23d, though he succumbed to meningitis 
upon the latter date. This ultimately unfavorable issue Mr. Godlee is in- 
clined to attribute to some defect in the antiseptic precautions. Whether 
this be so or not, the case well illustrates the very bold surgery that may 
justifiably be resorted to in a case that is otherwise hopeless. By a care- 
ful and minute study of the paralyses which were present, a very accurate 
diagnosis, both as to the size and location of the tumor, was arrived at ; 
and although the ultimate issue was fatal, it must remain a problem 
whether more scrupulous care in the use of antiseptic methods might not 
have averted the inflammatory processes which caused death. Certain 
it is that this one case goes as far as one case can to prove that cerebral 
localization is an established fact of which the surgeon may avail him- 
self in similar conditions. Published at about the time Dr. Roberts's 
paper was read, this interesting case does something to fortify and 
strengthen his position. It is worthy of especial note that Dr. Bennett 
and Mr. Godlee, in great measure, disregarded the local symptoms, such 
as a tender spot, relying chiefly upon the physiological ones, and that the 
tumor was not situated upon the side of the head originally injured. 

But this case does not stand alone, and Dr. Roberts refers to several 
others in which the same steps were pursued ; yet beyond two, as yet 
unpublished, by Macewen, of Glasgow, the records do not tell of a case 
in which life has been preserved by the proceeding, and the dictum of 
John Ashhurst, that the investigations of students of this subject " are 
more ingenious than practically useful," remains to be contradicted by 
more extended experience. This fact, however, should not lead to dis- 
couragement, as the subject is yet new, and we may still look for better 
results in the hands of daring and enthusiastic surgeons. 

We have been led somewhat into a by-path by the details of this 
interesting case, and it is time that we directed attention to the many 
other and important teachings contained in this brochure of Dr. Roberts. 
In the first place, our author commits himself very fully to the opinion 
that the symptoms usually attributed to compression of the brain are in 
reality due to intracranial inflammation. That this is very often the 
truth will be admitted by most surgeons, yet there will be found some 
who will point to a few recorded cases in which the symptoms have ap- 
peared coincidently with the injury, and have been promptly relieved 
upon elevation of the depressed bone. For ourselves we are inclined, 
with most others, to attribute the speedy appearance of the symptoms to 
contusion or laceration of the brain substance, and we have not seen any 
cases like those classical ones in which there was instant return to con- 
sciousness as the bone was lifted. 



RECENT BRAIN SURGERY. 171 

The second article of Dr. Roberts's creed is that, owing to improved 
methods of treatment, risk to life is but little increased by making an 
incision which converts a simple fracture of the cranium into a compound 
one. The third article of belief is the famous one in which our author 
states his conviction that the proper removal of portions of the cranium 
causes little more risk to life than amputation through a metacarpal 
bone. In these two articles Dr. Roberts goes very far, and for the latter 
one he was subjected to a good deal of criticism by the members of the 
Surgical Association, and we think with justice. Enthusiasm is very 
well, indeed it is a most desirable quality, but there is no use in be- 
littling the serious dangers attending an operation. We may decide to 
do an operation undeterred by its risks, but we will do wisely to approach 
it with our eyes open, and prepared to face its dangers. For ourselves, 
we should much prefer to undergo a metacarpal amputation to a tre- 
phining, and we should be very unwilling to have a long incision made 
in the scalp that the surgeon may have the satisfaction of knowing that 
there is no fracture, as was done with Dr. Roberts's approval in one case 
he cites. We have some confidence in antiseptic methods, but we should 
be sorry to convert a simple fissured fracture of the skull into a com- 
pound one, nevertheless. We might possibly forget some antiseptic 
precaution, and certainly the relations of the skull-cap, anatomically 
considered, are more important than those of any metacarpal bone. 
While we venture thus to differ with Dr. Roberts, we think with him 
that the dangers of trephining per se have been exaggerated, and the 
figures he gives do much to establish his position. 

Dr. Roberts's fourth proposition is that in the majority of cranial frac- 
tures the inner table is more splintered than the outer one, and from this 
he goes on to argue in favor of early preventive trephining, believing 
that it is more frequently demanded for purposes of exploration than as 
a therapeutic measure. He may be right as to the relative frequency of 
splintering of the internal table, at least in those where there is any 
depression ; but despite our author's conviction of the innocuousness of 
trephining, we cannot but look with doubt upon the formulation of a rule 
of practice unsupported by a large series of accurate observations estab- 
lishing the pathological fact upon which it is based. 

Going on to the sixth proposition of our author, we see no reason to 
oppose his view that drainage is urgently demanded in wounds penetrat- 
ing the cranial cavity ; nor, in the face of the very unfavorable statistics 
obtained in gunshot wounds by the expectant method, can any harm 
follow the adoption of his advice, always to trephine in every such injury. 
Yet we would certainly hesitate to do as Dr. Roberts says he did on one 
occasion — insert the little finger for its entire length into the cerebral 
wound in an attempt to touch the bullet. Neither do we see reason to 
differ from the propositions that the cerebral hemispheres may be incised 
with comparative impunity, and that wounds of meningeal arteries or 
cerebral sinuses should be treated on the same principles which guide us 
in controlling hemorrhage elsewhere. 

The ninth proposition laid down by Dr. Roberts deals with the im- 
portance of surgeons familiarizing themselves with the results of the 
study of cerebral localization. To this subject an entire chapter is 
devoted — and it bears the marks of careful, conscientious study upon 
every page. It is abundantly supplied with diagrams, and has a valu- 
able table, which sets forth in categorical fashion the state of our knowl- 



172 KEVIEWS. 

edge upon this interesting subject, as understood at the time the essay 
was prepared. It is enough to say that whoever wishes to become 
acquainted with this matter cannot do better than study this admirable 
chapter. Dr. Roberts reminds his readers that much of the ground 
covered by this chapter is debatable, which is very true, but yet it is 
ground upon which more and more certain advances are made every 
day ; and we do not doubt that while there may be many corrections to 
be made in our author's scheme, there remains much that is not likely 
to be removed by further research, though there will unquestionably be 
many additions made to it. We do not know that neurologists will admit 
that it is more important for surgeons to be acquainted with their work 
than they are themselves, as Dr. Roberts thinks, but we do think that it 
is a subject which no surgeon can afford to neglect. 

Into the details of treatment which Dr. Roberts proposes we cannot 
go at length. It is sufficient to say that after enumerating the various 
injuries and ailments which may cause the propriety of trephining to be 
considered, the chief remedy is the trephine. There are very few conditions 
where the use of this instrument is not directed as possibly, probably, or 
certainly the appropriate remedy. 

As we have before said, Dr. Roberts is enthusiastic in his advocacy of 
trephining, and he concludes this admirable essay with most sanguine 
anticipations of the future of that operation. He thinks that "in frac- 
tures, hemorrhage, and abscess, perforation of the skull will soon become 
quite common." While he is sure that in certain conditions, epilepsy, 
insanity, and tumor can only be successfully treated by operation, he 
recognizes the fact that the profession will be more slow to resort to such 
measures in cases of disease. 

For ourselves, we do not doubt that our author's views will prevail 
more or less, their positiveness and apparent theoretical soundness will 
secure this ; but after the test of experience has been applied, and the 
doctor has bored a large number of cranial holes, we question whether 
he retains all his enthusiasm, or remains satisfied as to the absolute cor- 
rectness of all his attractive theories. This monograph, however, will 
exert an influence, and give an impetus to trephining, and the issue 
must be left to time. 

The length at which we have discussed the subject presented by Dr. 
Roberts, will prevent our giving more than a cursory notice to the re- 
mainder of this large and handsome volume. But in adopting this course 
we hope it will not be thought that we lightly esteem the value of many 
of the articles passed over in silence. Three of them are experimental 
studies : one on Surgical Bacteria, by H. C. Ernst, of Boston ; and one, 
the longest in the volume, on Air Embolism, by Senn, of Milwaukee; 
while a third, by J. C. Warren, of Boston, deals in an admirable way 
with that ever interesting and important subject, The healing of arteries 
after ligature. 

An admirably instructive paper is one in which Professor S. W. Gross 
judicially considers Nephrectomy : its indications and contraindications, 
on the basis of 233 cases he has collated. In a terse, clear article, headed 
Nephrolithotomy, Dr. L. McLane Tiffany tells of the now famous case in 
which he successfully removed from the kidney a phosphate of lime con- 
cretion weighing 556 grains, and discusses the merits and indications for 
the operation in the light shed upon it by our present experience. 
Although this case attracted much attention at the time it was reported, 



DISEASES OF RESPIRATORY PASSAGES, ETC. 173 

its authoritative narration may be advantageously studied by any surgeon 
called upon to consider the propriety of resorting to the same operation. 

Another very interesting narrative is the Report of a case of cholecystot- 
omy, by Dr. C. T. Parkes, of Chicago, where the gall-bladder was twice 
opened in the same patient, and with complete ultimate success. After 
the first operation some small gall-stones were removed, but the obstruc- 
tion of the common duct appeared rather to depend upon inspissated 
mucus. 

Dr. John W. S. Gouley contributes Some points in the surgery of the 
hypertrophied prostate, in which he pays a high compliment to the labors of 
Mercier, of Paris. The paper abounds in practical suggestions, founded 
on the extensive experience of its author, and should be widely read. The 
same is true of a paper on Phosphorus-necrosis of the jaws, presented by 
Dr. Mears, who gives his exceptional experience with this most serious 
affection, and formulates the conclusions as to treatment that he has 
arrived at. This paper is abundantly illustrated, and it is to be hoped 
that the antidotal and preventive value of turpentine in counteracting 
the deleterious effects of phosphorous fumes will not be neglected. 

The etiology of traumatic tetanus is considered by Dr. P. S. Connor, in 
an interesting and most suggestive paper, in which the question is raised 
whether the true explanation of the origin of this hitherto inexplicable 
phenomenon may not possibly be found in some microbe. In the discus- 
sion that follows, it was evident that the members of the Association had 
not any settled conviction which would be rudely dispelled by any new 
theory. The volume concludes with a Device for atmospheric purification, 
by Dr. Prince, of Illinois. 

In thus so summarily going over the contents of this volume, we feel 
that we owe an a]:>ology to its contributors for such insufficient notices of 
the papers they have prepared ; while we warn our readers that they 
must not judge of the value of those papers by the length at which we 
have been able to speak of them. Altogether this volume tells of a 
vigorous and active association, fairly representative of the surgical sci- 
ence of the country. Its members are to be congratulated upon the good 
work thus far accomplished, and which may justly be regarded as the 
harbinger of future achievements. S. A. 



Hecent Works on Diseases of the Larynx and Respiratory Passages. 

1. The Therapeutics of the Respiratory Passages. By Prosser 
James, M.D., Lecturer on Materia Medica at the London Hospital Medi- 
cal College, etc. Pp. 316. New York: Wm. Wood & Co., 1884. 

2. Laryngoscopy and Rhinoscopy. Fourth edition, enlarged, with 
hand-colored plates. By Prosser James, M.D. Pp. 222. New York: 
Wm. Wood & Co., 1885. 

3. Diseases of the Larynx. By Dr. J. Gottstein, Lecturer at the Uni- 
versity of Breslau. Translated and added to by P. McBride, M.D., of 
Edinburgh. Pp. 270. Edinburgh and Lond. : W. & A. K. Johnston, 1885. 

1. This excellent brochure is intended, as the author tells us in his 
preface, " mainly for those who have left the schools and entered upon 



174 REVIEWS. 

the responsibilities of practice," and we venture to add that there are 
few of the class to whom it is dedicated who will not derive some infor- 
mation and pleasure from the perusal of its pages. 

The title is, to a certain extent, misleading. The author has called it 
" Therapeutics of the Respiratory Passages," but it embraces a much 
wider range, and must be regarded rather in the light of a systematic 
treatise on some of the more important articles of the materia medica. 
After a short introductory chapter, and one on nutrition in its relation 
to therapeutics, over forty pages are devoted to the discussion of the 
physiology of respiration, the preparation of food stuffs, the composition 
and physiological properties of the digestive juices and the consideration 
of aliments as remedies. Seventeen pages follow on " Iron " and " Phos- 
phorus and its Compounds." The author very properly cautions against 
the injudicious use of phosphorus in phthisis — a warning which is par- 
ticularly appropriate in view of the indiscriminate way in which it is at 
present administered in that disease. He furthermore considers the 
curative value of the hypophosphites insisted on by Churchill as exagge- 
rated, nor has he seen much benefit from their employment in chronic 
bronchitis and emphysema, the cases most benefited being those of in- 
cipient phthisis, without fever and haemoptysis, and chronic fibroid 
degeneration of the lung. 

Separate chapters are devoted to the subjects of digestion, transfusion, 
beverages, exercise and rest, and alcohol, which also include brief para- 
graphs on injections into serous cavities and the hypodermatic injection 
of blood and other fluids. The important subject of rectal alimentation is 
dismissed in a very brief manner, while the incomplete section on coca 
and cocaine, or, as the author prefers to call them, " cuca " and " cucaine," 
was probably written before the discovery of Roller. 

Dr. James treats of remedies directed toward the cure of respiratory 
affections under the following classification : 

(I.) Denutrients, including (1) antiphlogistics, (2) bleeding, (3) coun- 
ter-irritation, (4) evacuants, (5) mercury, {6) diaphoretics. 

(II.) Antipyretics, including (1) cold, (2) quinia, (3) salicin, (4) kairin, 
(5) veratria, (6) digitalis, (7) aconite, etc. 

(III.) Neurotics (narcotics). 

(IV.) Pneumatics, including (1) expectorants, (2) antiseptics and dis- 
infectants, (3) anodynes and sedatives, (4) contra-expectorants, (5) cen- 
tral pneumatics. 

(V.) Topical Pneumatics (inhalations and other topical applications). 

It would be impossible to criticise, within the limits of this review, 
the author's comments on the individual members of this classification. 
Suffice it to say, that whatever may be said of the latter, Dr. James has 
given us an interesting and instructive account of the principal effects 
and uses of these remedies, which is still further enriched by many mat- 
ters of historical value, and which is in agreeable contrast to the arid 
narrative of many works on therapeutics. The section on topical pneu- 
matics is incomplete and disappointing, and we are amazed at the 
author's apparent ignorance of the improved methods of topical medica- 
tion of the upper air-passages in common use among American specialists. 
The subject of medicated sprays is dismissed with the merest reference, 
while considerable space is given to the more antiquated methods of 
gargling and the nasal douche. Regurgitation of fluids through the 
nose is spoken of as a " natural nasal douche", from which we can often 



DISEASES OF RESPIRATORY PASSAGES, ETC. 175 

obtain most satisfactory results, but we are rather inclined to regard this 
method as an unphysiological procedure and a circuitous way of accom- 
plishing a great deal of possible harm with considerable difficulty and 
personal inconvenience, and the same may be said of the laryngeal gargle 
of Monsieur Guinier. It is true that gargles are occasionally of benefit, 
but the sphere of their usefulness is contracted. Even by the so-called 
method of Troeltsch, very little of the fluid reaches the deeper portions 
of the throat, and as all communication between the upper and lower 
pharynx is cut off during the act, the remedy does not reach the spot 
it is designed to medicate. The contraction of the palatopharyngeal 
muscles may, however, be of service in the mechanical dislodgement 
of mucus from the nasopharyngeal space. We have found it useful 
also to direct the patient to assume the recumbent posture with the head 
thrown slightly back, and allow the fluid to gravitate into the pharynx. 
In strongly recommending alum as a gargle, the author should, we think, 
have cautioned against the injurious effects of this agent on the teeth. 

We regard the nasal douche as a remedy of questionable utility, even 
when used with the precautions insisted upon by the advocates of its use, 
whilst its indiscriminate use, as indulged in by many even at the present 
day, cannot be too severely condemned. It by no means accomplishes 
what is claimed for it; but, on the other hand, subjects the patient to 
many possible and unnecessary dangers. Besides the acute inflamma- 
tion and abscess of the middle ear so often caused by its employment, 
it tends to aggravate the nasal trouble, and we have known chronic in- 
flammation of the tympanic cavity to follow the prolonged use of this 
remedy. We have also known the severest form of acute otitis media 
follow the use of the post-nasal syringe, so often employed by the 
general practitioner, and even by specialists. 

Dr. James is an easy writer and a man of scholarly tastes, and his 
book is written in an agreeable style, which at times is rather prolix 
and pedantic, but which enlists the interest of the reader to the end. 
Unlike many other therapeutists, he does not laud the infallibility of 
drugs, the applications of which are things based upon strictly experi- 
mental inquiries, but is disposed to regard them in the light of clinical 
experience and practical results. Although the careless w r ay in which a 
great part of the reference work has been done, and, indeed, the quota- 
tion on page after page of authors without giving any references at all, 
may awaken in the minds of those who are not acquainted with the 
author grave suspicion of borrowed erudition, still the work represents 
a great deal of painstaking literary labor, and, taken as a whole, we can 
confidently recommend it both to the special worker and general practi- 
tioner as a valuable contribution to the literature of respiratory thera- 
peutics. 

2. This is practically the fourth edition, with additions, of the author's 
little primer on " Sore Throat," but invested with a more appropriate 
title. Within the bounds of such a small volume, it would be impos- 
sible to treat in a satisfactory manner, even for a beginner, the subject 
of rhinology and laryngology, and we think, therefore, the present title 
more exactly definitive of its legitimate scope. 

In calling attention to the general excellence of this little manual, 
the third edition of which has already been reviewed in this journal, we 
feel it our duty at the same time to point out some of its more noticeable 



17(3 REVIEWS. 

defects. In the first place, we think the author too frequently creates 
an injurious impression, by arrogating to himself credit of priority and 
invention in matters of infinitesimally small importance, and which 
every student will discover in the alphabet of his special studies. His 
implied claims, too, in the matter of the tongue dej:>ressor known as 
" Tiirek's," and the nasal speculum of Frankel, are unfortunately un- 
supported by any of the published evidence which historical accuracy de- 
mands as the test of priority in discovery. 

There are other matters which we think are calculated to bewilder 
the student. In attempting, for example, to elucidate the theory of 
laryngoscopy on page 54 by the inverted word " glottis," we can scarcely 
conceive of a more certain way of producing in the student's mind the 
very opposite of a lucid illustration. We would also caution the tyro 
against mistaking the figure on page 90 for the normal appearance of 
the posterior nares, as seen in the rhinoscopic mirror. As an attempt 
to portray a well-marked case of hypertrophic catarrhal rhinitis, pro- 
ducing almost complete occlusion of the nares, the diagram would have 
been a marked success; but between the condition there depicted and the 
normal appearance of the parts, there is not the slightest shadow of a 
resemblance. 

It is a disagreeable task to criticise the artistic tastes of our author, 
but Ave would also strongly advise the student not to examine the colored 
plates at the end of the volume until he has thoroughly familiarized 
himself with the laryngoscopic conditions Avhich they represent in the 
living subject. We say this in no captious spirit, but because we regard 
it as a point of the gravest importance. First impressions of patholog- 
ical conditions derived from diagrams and other forms of pictorial illus- 
tration, are often very difficult to eradicate, and the colored plates of 
this manual are more calculated to give erroneous impression than to 
instruct. ® n ! 

Occasionally a loose statement is encountered, such as that found on 
page 91, that in the normal posterior rhinoscopic image " the septum 
nasi seldom occupies the exact centre of the image, but leans a little to 
one side or other, so that we rarely see a rhinoscopic image precisely 
symmetrical." As a matter of fact, deflection of the posterior third of 
the vomer is one of the rarest of curiosities, the position of its posterior 
border being almost invariably median and perpendicular — and we can 
recall only two recorded cases of deflection in this situation — one reported 
by Prof. Wenzel Gruber, of St. Petersburg, and one by the writer of this 
review. 

We have always wondered why the orifice of the Eustachian tube, as 
seen with the rhinoscope, should be universally described as " trumpet- 
shaped," and have thought that its comparison to an enlarged cervix 
uteri comes nearer the conception of its actual appearance. 

Several instruments are figured and their uses dilated upon, which 
the student will probably never use. We had thought, for example, 
that the laryngeal syringe had long since been relegated to the limbo of 
museum curiosities, but the author figures three different varieties and 
devotes considerable space to their use. Few, we believe, would resort 
to the method at the present day, who had in their possession the 
simplest form of spray apparatus, or who could command the services of 
a probe and a piece of absorbent cotton. Nor do we think that the re- 



DISEASES OF RESPIRATORY PASSAGES, ETC. 177 

moval of the uvula by means of the ancient " sickle " would be chosen 
in preference to its ablation by a pair of ordinary uvula scissors. 

The space devoted to rhinoscopy and its difficulties, is hardly com- 
mensurate, we think, with the importance of this method of diagnosis, 
while little or nothing is said concerning the morbid conditions which 
the use of this procedure reveals. 

Notwithstanding its defects, the book is one of merit and contains 
much valuable information for the beginner. 

3. While the necessity for the translation of Dr. Gottstein's monograph 
is not as obvious as is implied in the preface of the translator, we can, 
nevertheless, recommend it to those unacquainted with German as an 
excellent and faithful presentation of the commoner affections of the 
larynx. 

The first sixty-one pages include chapters on the anatomy and physi- 
ology of the larynx, general etiology, diagnosis, symptoms, and treat- 
ment. Laryngeal affections are divided into primary (diseases of the 
mucous membrane, perichondrium and cartilage, wounds and injuries, 
adhesions and cicatricial contractions, neoplasms, lupus, leprosy, foreign 
bodies, neuroses) and secondary (tuberculosis, syphilis, measles, scarla- 
tina, smallpox, typhoid and typhus fever, erysipelas and whooping- 
cough) — a classification which is not strictly accurate and logical, for, as 
the translator correctly points out, neither laryngeal lupus nor lepra is a 
primary affection, and we may add that, as disease of the mucous mem- 
brane, cartilage and perichondrium, neoplasms and neuroses may be 
either primary or secondary, and to a large extent the latter is the case, 
the separation of laryngeal diseases proposed by the author is both arti- 
ficial and calculated to mislead. 

The subject of etiology is briefly dismissed in the usual stereotyped 
manner common to all works on laryngeal disease. If the translation be 
a literal one, the nasal cavity, " intended to warm and purify the inspired 
air," is spoken of as imperfectly fulfilling this function, and the inference 
is drawn that atmospheric changes influence the mucous membrane of 
the larynx directly through this imperfect but natural discharge of func- 
tion. We cannot support the insinuation that laryngeal disease may be 
due to a naturally imperfect discharge of function on the part of the 
nasal cavities. The dependence of affections of the windpipe upon per- 
verted nasal function is quite another thing, and we become every day 
more impressed with the conviction that the great secret in the treatment 
of laryngeal disease resides in the recognition of the fact, that the vast 
majority of cases of catarrhal laryngitis are secondary to or sequels of 
a diseased condition of the nasal passages. 

In the matter of therapeutics, the author recommends measures which 
for the most part are severer than those used in this country. His 
preference for the sponge and brush for topical applications over the 
medicated spray, which latter he finds unsatisfactory, will not be shared 
by his colleagues on this side of the Atlantic. 

Of the excellent chapters in Part II , that on " Neuroses" is the most 
interesting to the specialist, although the author fails to discuss many of 
the moot points in the pathology of this class of laryngeal affections. 

Part III. opens with the discussion of laryngeal tuberculosis — a sub- 
ject of surpassing interest both to the specialist and general practitioner 
— and considerable space (twenty-six pages) is very properly given to 

NO. CLXXXIII. — JULY, 1886. 12 



178 REVIEWS. 

this affection. The question of primary invasion of the larynx in tuber- 
culosis is left sub jitdice, although such a view " derives some support 
from recent researches on the parasitic nature of tuberculosis." Although 
the laryngoscope has apparently thrown much light upon the problem, 
the primary occurrence of tubercle in the larynx can only be definitely 
determined by post-mortem evidence, and in this connection we would 
call attention to the recent claim of Orth, that he has found tubercle in 
the larynx unconnected with disease of the pulmonary tissue. 

Dr. Gottstein very correctly considers that pressure on the recurrent 
nerve by the infiltrated lung tissue is insufficient to account for the 
paresis and paralysis of the laryngeal muscles in the first and second 
stages of phthisis, preferring, with the majority of writers, to ascribe 
them to defective innervation, the accompanying catarrh, or to the 
granular changes in the muscles described by E. Franckel. That in 
some cases they may be due to the deposit of miliary tubercles in the 
muscle fibres, and between the fibrillar is also probable from the changes 
in the laryngeal muscles described by Heinze, 1 and the writer of this 
review. 2 

Very little space is given to the discussion of the much controverted 
question of the aphthous, or, as we would prefer to call them, diphtheritic 
ulcerations, so often met with in the windpipe, and more particularly the 
trachea, in the later stages of pulmonary tuberculosis. We have given 
at length elsewhere 3 our reasons for regarding this form of ulceration as 
distinct on the one hand from catarrhal, and on the other from the char- 
acteristic tubercular ulcer found in the larynx and trachea. Even in 
the light of the new gospel of tuberculosis, we consider it by no means 
proven that true tubercular infiltration and ulceration of the windpipe 
are due either to the direct action of bacilli from without or to the 
j)resence of these parasites in the sputa. The tubercular process, as 
shown by Heinze, commences under the epithelium, whereas in the ulcers 
we are reviewing, that structure is always first affected. We regard it, 
then, as extremely probable that diphtheritic, as contradistinguished 
from tubercular, ulceration of the windpipe in pulmonary phthisis is due 
to an inoculation, so to speak, of the mucous membrane with the detritus 
of the broken-down pulmonary tissues, leading to a loss of substance 
pathologically distinct from the ulcer commonly known as "tubercular," 
but possessing some of its external appearances — a view which seems to 
us to reconcile the widely divergent opinions upon this subject and which 
reduces the influence of the sputa in the production of laryngeal and 
tracheal ulceration to more definite and appreciable dimensions. Not- 
withstanding, however, the fact that diphtheritic ulceration owes its 
existence to the pulmonary disintegration, and is therefore intimately 
related to the tubercular process; notwithstanding the possible future 
discovery of the constant presence of bacilli in these ulcers, it would be 
unsafe to regard them as specific tubercular products, until the whole 
pathological anatomy of tubercle be changed, so that the essential pathog- 
nomonic histological evidence of tuberculosis be drawn not from a w T ell- 
defined characteristic structural lesion, but from any tissue change that 
contains a bacillus. 

1 Die Kehlkopfschwindsackt, Leipzig, 1876. 

2 Archives of Medicine, New York, Oct. 1882. 

3 Monatssehrift fur Ohrenheilkunde, etc., Berlin, No. 9, 1881, and Trans. Medico-Ckir. Faculty ot 
Maryland, 1882. 



ETC. 179 

We find no reference in this excellent chapter to that interesting form 
of laryngeal tuberculosis in which solitary tubercular tumors are met 
with composed of an aggregation of miliary tubercles unassociated with 
infiltration and ulceration of the surrounding mucous membrane, which 
was first described in 1882, 1 and of which other examples have been since 
recorded. 

In regard to the frequency of laryngeal disease in syphilis, the author 
regards the statistics of Lewin, who found the larynx affected 575 times 
in 20,000 patients, as the most reliable. This question is one which has 
always given rise to much dispute, and about which statistics differ very 
widely. While we do not propose in this review to enter into a critical 
examination of the sources of error discoverable in the antagonistic re- 
ports of different observers, it may be said, in general, that reconciliation 
of diverging opinions upon this subject can only be accomplished by 
taking the life-histories of the cases upon which the statistical evidence 
is based. Were this matter universally adopted, we believe that few 
syphilitics would be found who had not, at some period or other of the 
disease, suffered from some form of laryngeal affection. While it is 
probable, therefore, that the majority of cases, if untreated or neglected, 
will sooner or later develop some phase of laryngeal disorder, it is equally 
certain that the eruption of the disease in the larynx can be prevented 
or modified by early therapeutic interference. As the virulence of 
syphilitic lesions in general is modified by the employment of the more 
advanced and rational methods for its cure, so the destructive affections 
of the larynx are less frequently met with now, than in the time when 
the therapeutics of the disease were less perfectly understood, and when 
the exhibition of mercury to salivation was the catholicon of the pro- 
fession. 

We must take exception to the statement of the author in regard to 
the rarity of laryngeal syphilis in childhood. Some time ago we took the 
trouble to investigate this matter, and were surprised to find how fre- 
quently laryngeal disease is met with in the congenital form of syphilis. 
So far from being an uncommon occurrence to find the larynx involved, 
we soon came to regard such an event as one of the most constant patho- 
logical phenomena of congenital syphilis, to be looked for with the same 
confidence as in the acquired form of the disease. 2 

Short sections on the larynx in scarlet fever, typhus, etc., with an ap- 
pendix in which the translator gives a resume of recent observations on 
the innervation of the larynx, and adds an interesting case of so-called 
"chorea laryngis" which he believes lends support to the glottic spasm 
theory of this condition, complete the volume. 

Although as an essay on laryngeal affections it is in some respects in- 
complete, the brochure of Dr. Gottstein is one of more than ordinary 
merit. His descriptions are clearly written, and accurate, and his com- 
ments on moot points as a rule eminently judicious. Many omissions 
occur, it is true, and many authors are not referred to whose names de- 
serve mention in every work on diseases of the larynx, but these faults 
doubtless arise from the author's apparent unfamiliarity with foreign 
literature and to the contracted sphere of his literary researches. 

In the English edition several typographical errors occur, and mistakes 

1 Archives of Medicine, N. Y., Oct. 1882. 

2 For a full account of the throat affections of congenital syphilis, see the October number of this 
journal for 1880. 



180 REVIEWS. 

in the spelling of proper names. Thus, for example Tuerck figures 
throughout the volume as " Tuerk," and Oliver as " Ollivier." Apart from 
this, the general get up of the work is excellent, and reflects credit on 
the English publisher. 

The task of the translator is, as a rule, a laborious and thankless one, 
and we take, therefore, great pleasure in congratulating Dr. McJBride 
upon the entirely satisfactory manner in which he has converted the 
German original into pure and readable English. J. N. M. 



A Handbook on the Diseases of the Nervous System. By James 
Eoss, M.D., F.R.C.P., LLD., Senior Assistant Physician to the Man- 
chester Royal Infirmary, etc. 8vo. pp. 726. With 184 illustrations. 
Philadelphia: Lea Brothers & Co. London: J. & A. Churchill, 1885. 

If this volume had been entitled " A Handbook of the Anatomy, 
Physiology, and General Symptomatology of the Nervous System," we 
should find in it less to criticise and more to commend. But as it is 
called a " Handbook of the Diseases of the Nervous System," and as 
the author boldly says in his preface that it " is intended for the use ot 
students, and such of my professional brethren as are so fully occupied 
in practice that little time is left to them for reading lengthy treatises 
and monographs on special subjects," both the arrangement and matter 
of the book call for decided criticism. It is with sincere regret that we 
say this, for it would be much more pleasant to praise highly the result 
of so much labor, so much study, and so much research. 

Although no mention of the larger work is made in the preface, this 
volume is an abridgment of a treatise on The Diseases of the Nervous 
System, in two volumes, published in 1882, and reviewed at some length in 
the July number of this journal for that year. In this review some pains 
were taken to put side by side quotations from the works of Erb and 
Nothnagel, in Ziemssen's Cyclopcedia, and the text of Dr. Ross's book 
which indicated that " several volumes of Ziemssen's Cyclopcedia have 
been made use of with a freedom which only a liberal application of 
quotation marks could warrant," and that Dr. Ross "has not only 
plagiarized references, but has transcribed sentences and paragraphs 
without acknowledgment." Hence, our present task will lie in a different 
direction, and after making a hasty reference to the first part of the 
volume, which, as Dr. Ross says, is devoted to " General Neurology," and 
which occupies one-third of the book, we shall confine ourselves to the 
second part, or " Special Pathology of the Nervous System." 

The first part of the book is a perfect treasury of knowledge collected 
from all possible sources. Apart from the unnecessary complication of 
symptoms and the compound names, which tend to make a difficult 
subject more difficult, this portion of the book is probably the best 
resume of the general physiology and symptomatology of the nervous 
system that has yet been issued. It has been written with great care, 
the plates are very good, and particularly those showing the interde- 
pendence of the cerebro-spinal system, or, as Dr. Ross puts it,- the 
encephalo-spino-neural system. The first part of the book alone makes 



ROSS', DISEASES OF THE NERVOUS SYSTEM. 181 

it valuable in any library because the information it contains could 
only be obtained with endless trouble from many authors. 

The anatomical and physiological introduction and the consideration 
of the general morbid anatomy and physiology of the nervous system 
form a very good and clear exposition of what is now known on this 
subject. When, however, Dr. Ross reaches the 125th page and com- 
mences the consideration of the general symptomatology of the nervous 
system, he adopts a wordy nomenclature which is always to be avoided. 
Hyperpselaphisia, apselapsia, and allochiria, etc., could have been very 
well omitted in a work where space was valuable. 

The first part concludes with a chapter on " General Treatment," 
which includes hydropathy, rest cure, Swedish movement cures, the 
mechanical vibrations of Dr. Mortimer Granville, and electricity in 
thirteen pages, leaving only two pages to internal remedies. 

In the second part of Dr. Ross's book we find a faulty and laborious 
classification, a minute division of minor subjects, and a most superficial 
treatment of some of the most important troubles that daily come under 
the care of every neurologist. And we may add with great truth that 
Dr. Ross has neglected to give a place in his " Clinical Classification " 
to some most interesting and important diseases of the nervous system. 
There is no mention whatever of melancholia or insanity of any kind, 
or of Basedow's diseases, or hydrophobia. 

The study of medicine has for its aim not only the acquisition of 
knowledge concerning disease, but also the attainment of skill and 
ability to cure the many ailments which afflict mankind. This is by 
far the most important and, in fact, the sole origin of medicine as a 
profession. If cure is impossible, then, at least, it is the duty of the 
physician in his school and in his books to teach the alleviation of 
suffering to the fullest extent. 

The elaboration of medical treatises on various special subjects has 
been of late years the ambition of many authors, and the result is that 
the press is teeming with such books. Dr. Ross is an example of this 
tendency, and without anything new to say, no clinical knowledge to 
impart, and with an unparalleled neglect of the just and proper use of 
quotation marks, he has compiled from many authors a treatise in which 
diseases of the nervous system are divided and subdivided in a most 
complicated classification. The result of this effort is that many unim- 
portant and useless subdivisions occupy the space which should have 
been devoted to acute and prevalent diseases. In fact, where there is 
no clinical necessity he has elaborated, and where there exists great 
clinical want he is silent or superficial. 

In a " Handbook of the Diseases of the Nervous System" w T e should 
expect to find at least some well-organized treatment for the most curable 
and common troubles that we are daily called upon to treat. But the 
busy practitioner wishing, for example, to see what Dr. Ross recommends 
for trigeminal neuralgia, would find the treatment thereof nearly fifty 
pages removed from the description of the disease, and when he does at 
length find it in a most unlooked for and unlikely position, his reward 
is small and unprofitable. The treatment of megrim is even less satis- 
factory. The consideration of this important neurosis is included in a 
chapter with spinal irritation, neurasthenia, and headache, and is 
dismissed with a very cursory description. Guarana (Paullina sorbilis), 
which has quite a reputation among many neurologists as a remedy for 



182 KEVIEWS. 

megrim, is called " Guarma powder/' and is merely mentioned. To 
show the importance of this subject in a clinical point of view, we may 
say that the treatment of megrim in Liveing's book on this malady fills 
fifty-four pages, and that even an epitome of this most valuable chapter 
would add much to any work on nervous diseases. 

In the section on "Neurasthenia" in the same chapter, Dr. Ross has 
made very apparent use of the writings of the late Dr. Beard without 
ever once alluding to his name. This author was fond of word-making 
and compounded from the Greek many strange-sounding names to ex- 
plain the various phases of that apprehension, or torment from within, 
which is a prominent symptom of mild forms of melancholia or hypo- 
chondriasis. Dr. Ross has, however, missed the highest creation of that 
lamented medical philologist, who, after exhausting every other fear, or 
the fear of everything else, put a climax to his long list of symptoms 
by coining the word phobophobia, or fear of fears. 

Chapter III. commences the consideration of " Spasmodic Disorders," 
which are divided into spino-neural spasms and cerebrospinal spasms. 
By what system of reasoning, clinical or anatomical, Dr. Ross can in- 
clude " spasms of the muscles of the eyeball " or " spasms in the area 
of distribution of the facial nerve" in the classification of spino-neural 
spasm we do not comprehend. After giving a long list of rare and un- 
important muscular spasms, Dr. Ross comes to the consideration ot 
writer's cramp and other occupation pareses (or, according to the text 
of this volume, professional hyperkineses), to which important and com- 
plex subject he devotes two pages, saying among other things, " Tele- 
graphist's cramp has been met in France with the use of Morse's machine," 
inferring that this disorder exists among that unfortunate nation alone. 
The experience of every one will refute this singular idea of the French 
monopoly of telegrapher's spasm, for cases of this trouble are seen daily 
in every large city in this country. 

Tetanus is tersely considered in the chapter on " Spino-neural Spasms," 
but there is space enough for the description of such conditions as 
" emprosthotonos," " orthotonos," and " pleurosthotonos." The treat- 
ment of this important disease is given in the next chapter on " Cerebro- 
spinal Spasms," and is concluded in a few lines. Cerebro-spinal spasms 
are thus divided, " I. Spasms from organic disease of cortex of the 
brain: (1) Crural monospasm or protospasm ; (2) Brachial monospasm 
or protospasm; (3) Facial monospasm or protospasm; (4) Oculomotor 
monospasm or protospasm ; (5) Masticatory monospasm or protospasm." 
Then follows " II. Spasmodic affections from functional disease of cortex 
of the brain, a. Epilepsy, b. Eclampsia, c. Hysterical spasmodic affec- 
tions," etc. 

As epilepsy is frequently caused by injuries to the brain and is often 
connected with serious organic disease of that organ, we do not see the 
reason for placing it first among those diseases which arise " from func- 
tional disease of the cortex of the brain." The study of hysteria is a 
very simple matter occupying little over one page. Referring to hysteria 
in boys, Dr. Ross says, among other things, " The depraved form ot 
hysteria named chorea major is often met with in boys. In this variety 
of the disease the patients run, dance, jump, or climb with much greater 
readiness or dexterity than similar actions can be performed in health, 
or they may sing or recite poetry, even in a foreign language." We 



183 

hope this sentence may be generally understood by Dr. Ross's readers, 
but we candidly confess our inability to comprehend it. 

When, however, Dr. Ross comes to consider chorea major, he does not 
consider it at all. In fact, grouping " Chorea" in the same chapter 
with " Paralysis Agitans and Multiple Sclerosis of the Brain and Spinal 
Cord," he gives this very important disease less consideration than either 
of the others. He says, " Heredity plays an important part in the pro- 
duction of chorea, but the transmission is probably always indirect." 
But in this study of chorea he omits many important considerations, 
and we need hardly enumerate these omissions when we say that the 
treatment is condensed in twenty lines. In referring to Rosenthal, we 
find he devotes thirteen pages of his treatise to this disease, and RadclifFe, 
in Reynolds's System of Medicine, gives an excellent account of the same 
subject in thirty-eight pages. We are somewhat surprised to find so 
prevalent and so interesting a disease dismissed in such a cursory manner, 
for this malady is increasing in frequency and severity. 

It has been aptly said of the critic " that the temptation to exhibit 
his own cleverness at the author's expense is irresistible." This is a 
danger which an author runs when he writes a good book, but when his 
work does not reach the promises of his title-page, when it fails to give 
information on topics which most need elucidation, when its arrange- 
ment is bad and complicated, when it is burdened with turgid and useless 
names which tend to obscure rather than to simplify, Ave can find no 
reason to recommend such a work to those who need information con- 
cerning the diseases of the nervous system. Truly a most uncomfortable 
" handbook " when you have to search for certain diseases in the most 
unlikely places, and where the treatment of these maladies is as hard to 
find as a quotation from an obscure poet. J. V. B. 



The Management of Labor and of the Lying-in Period. A Guide 
for the Young Practitioner. By Henry G. Landis, A.M., M.D., 
Professor of Obstetrics and Diseases of Women in Starling Medical College, 
etc. 12mo. pp. 334. Philadelphia: Lea Brothers & Co., 1885. London: 
K Griffin & Son. 

The object of this book is set forth on the title-page and in the 
preface ; it is intended to be a guide to practice for the young practi- 
tioner, and not to deal with the needs of the student. We are com- 
pelled, in the interests of truth, to say that, while the exclusion of the 
student is advisable, we fail to see how a work so imperfect and so inac- 
curate can help the young practitioner. To illustrate our point, we will 
make a few quotations from the first chapter. On page 11 we are told 
that " Very little pain attends the contractions, unless disease of some 
sort has interfered with the proper action of the parts concerned. There 
should be no pain at all during the first stage." The first of these state- 
ments is absolutely untrue; the second, if a statement of fact, is also 
untrue, but it may be only a remonstrance with Providence. On page 
15 we are told that, "If a woman has a markedly painful labor, it is 
because personal or inherited violation of hygienic law has caused her 



184 EEVIEWS. 

to be afflicted with inflammatory or mechanical disabilities in the organs 
of parturition, and not because it is natural for women to suffer in 
childbirth." We should like to know what evidence can be produced 
for such a statement. On page 17, six hours is fixed as the "maximum 
limit of normal labor," a statement which, if it has any effect at all, 
can only tend to produce "meddlesome interfering" on the part of the 
"young practitioner." 

On page 18, the second stage is said to last "from ten minutes to an 
hour;" lower down, "it is painful to admit that, notwithstanding the 
teachings and practice of the best obstetricians, and the near approach 
of obstetrics to a science, there is a widespread tendency to non-interfer- 
ence." This statement, again, is at variance with facts ; the " best ob- 
stetricians" are the least meddlesome, and the whole history of modern 
midwifery has been in this direction. On page 19, the author goes so 
far as to speak of the " strong delusion that nature is all-sufficient, and 
that meddlesome interfering is bad." This is positively dangerous. 

On the same page we read that " corsets, high heels, failure to take 
exercise in the open air, abuse of the sexual organs, have brought it to 
pass that a woman is rarely in labor without some complication which 
may or may not be removed by obstetrical treatment." Most of this is 
simply empty talk. 

This takes us to jmge 21, the end of the first chapter. We cannot 
afford space to quote as freely from the remainder of the 329 pages, and 
can only pick out pieces here and there. On page 47 we read : " When 
once the head begins to press upon and stretch the perineum, the tenacity 
of the perineum is directly impaired by every degree of continuance of 
the labor. The longer the time taken to distend it, the more its circula- 
tion is impeded and its powers of cohesion diminished." This seems to 
us untrue, in the face of the well-established fact that gradual dilata- 
tion of the perineum is its greatest safeguard. Here, again, is a direct 
incentive to bad practice. 

On page 94 we read that, after measuring the external conjugate, 
" we then guess how thick the sacrum and dorsal tissues are, and how 
thick the symphysis must be, and, deducting these measurements, we 
can guess how long the conjugate diameter is, which might have been 
done without so much trouble in measuring." This is an inaccurate and 
unfair statement; the author gives no indication how much is to be 
deducted. About his pelvimetry we shall have something to say pres- 
ently. 

On the same page, a few lines lower down, he says: "When" (in 
measuring the diagonal conjugate) "we succeed in touching the pro- 
montory, we note exactly where the anterior vulvar commissure [!] 
touches the skin of the hand. From this point to the finger-tip we 
measure, and this will give us the diagonal conjugate (Fig. 8). Since 
the inner [!] face of the symphysis is perpendicular [which it is not], 
we have the hypothenuse of a right-angled triangle," etc. 

We cannot help saying that such statements as those just quoted 
would be sufficient to cause the rejection of a candidate in any good 
examination. We may dismiss the subject of pelvimetry and pelvic 
deformities by saying that the author never loses a chance of trying to 
throw ridicule on accuracy, and that he displays most imperfect knowl- 
edge of the subject — an instance of imfamiliarity breeding contempt. 

The chapter on hemorrhage before the birth of the child is meagre 



185 

and unsatisfactory, and bears no trace of the work lately done on the 
subject. In the chapter on hemorrhage after delivery we read, page 
105, that hot milk is the best drink, because " it is a near approach to 
blood;" why not then drink hot blood and get the actual thing? Hot 
milk is no doubt a good stimulant, but does milk or does blood taken by 
the mouth enter the circulation as milk or blood ? On the same page 
the author says : " So certain is our control in these matters, that a death 
from post-partum hemorrhage, occurring under the supervision of a 
physician, must compel him to remorseful thoughts." This statement is 
of the same nature as the popular one that no woman dies in her con- 
finement unless by some one's fault, and it is as accurate. On page 167 
we read : " The hypodermic injection of whiskey and ether has already 
proved of value, and it is possible that enough fluid can be thus in- 
jected," etc. This would seem to imply that the whiskey is expected to 
fill the circulation to the amount of the blood lost. On the same page, 
whiskey is said " to find its way into the lacteal secretion with celerity," 
which is untrue. Six small pages are devoted to the subject of rupture 
of the uterus. 

The chapter on septicaemia is incorrect and inadequate ; the author 
does not appear to have assimilated any of the results of recent, or even 
comparatively ancient research. Take such a sentence as the following 
(page 303) : " The real practical question is, whether external agencies 
may bring about the septic change when it would not otherwise originate. 
Can we carry any material poison, whether plain dirt or germs, which 
will convert an otherwise natural case into one of disease ?" Such a 
frame of mind may be one of repose for its possessor, but it is fraught 
with extreme danger to patients. 

We have spoken plainly, because teaching such as that contained in 
this book is, to our thinking, highly dangerous. We have only gathered 
specimens, but these could be multiplied at pleasure. Such a production 
as that before us is not creditable to a country which is doing good and 
serious work in midwifery, and which has produced so excellent a work 
on the subject as that by Lusk. We conclude our irksome task by 
recommending to our author the study of his countryman's book. 



The Surgical Diseases of Children. By Edmund Owen, M.B., F.R.C.S., 

Surgeon to the Hospital for Sick Children, Great Ormond Street, London. 
12mo. pp. 585, with four chromo-lithographic plates and eighty-five en- 
gravings. London: Cassell & Co. Philadelphia: Lea Brothers & Co., 1886. 

A very handy and convenient little volume, showing much pains- 
taking care upon the part of its author, as well as practical acquaintance 
with his subject. From the fact that it forms one in a series of clinical 
manuals, Mr. Owen has had to compress his subject within somewhat 
narrow limits, and, as a consequence, some interesting matters are treated 
with much brevity. The affections thus summarily dismissed are quite 
naturally those which are comparatively rare — yet they are the very 
ones that will prove most puzzling to the general practitioner, and for 
information concerning which he will very surely turn to a work on 



186 REVIEWS. 

children's diseases, when confronted by something with which he is not 
familiar. This difficulty must always be met with when the attempt is 
made to include a large topic in a small book, and the criticism implied 
in our words is applicable to the plan of the work rather than to the way 
in which Mr. Owen has discharged his task. 

The book is a thoroughly trustworthy manual of the surgery of chil- 
dren, based upon extended personal observation as well as careful study 
of surgical writers who have dealt with the same subject. We think 
there is a disposition on Mr. Owen's part to attach somewhat undue im- 
portance to some fleeting journal articles, and to put them upon a par 
with the teachings of those who have made for themselves reputations 
which entitle them to be regarded as authorities. Then Mr. Owen some- 
times contents himself with citing authorities by name and giving his 
readers the benefit of their often conflicting views, without a positive 
expression of his own opinion. This is very trying to many persons 
likely to consult such a volume. They do not look for encyclopaedic 
fulness of statement, and generally would prefer the simple dogmatic 
dictum of the author himself, and they are the more likely to do so in 
this case, because when Mr. Owen does speak for himself it is with a 
directness and soundness which leave nothing to be desired. 

But we have taken up sufficient space with preliminary observations, 
and hasten to notice some points which have especially attracted our 
attention. The first of these is tracheotomy for croup, which follows a 
very good chapter upon diphtheria. The steps of the operation are 
clearly described, and many practical hints are given, which will be 
appreciated by any one who has experienced the anxiety incident to 
the performance of the operation with insufficient assistance. That the 
operation is one which most surgeons regard with anxiety, is pretty well 
recognized. But we sometimes question whether the mass of literature 
dealing with tracheotomy is not in part responsible for the apprehension 
with which it is regarded. Not that we would for a moment be under- 
stood as belittling a proceeding which may w T ell try the soul of any sur- 
geon. But, after all, it is a proceeding for which there are very definite 
rules, which if carefully followed, ivitliout haste and with careful determi- 
nation, will lead to a successful result, at least for the time. It is the 
sad, ultimate issue which attends so large a number of cases, that makes 
many hesitate to resort to it. If obliged to act hastily, and minutes are 
often of vast importance, the risk of hemorrhage is one which is deservedly 
dreaded. Yet if the surgeon keeps in the middle line, here, if ever, the 
safe one, and eschews the use of cutting implements while making the 
deeper dissection, he will in most cases get down safely to the trachea. 
Mr. Owen recommends a bivalved tube as easy to introduce even when 
the tracheal wound is small. The same end can be attained by a guide 
with a conical end, which can be withdrawn so soon as the tube is fairly 
introduced. Mr. Owen advocates the use of chloroform in all cases. In 
this he differs from many surgeons, whose experience leads them to look 
with doubt upon anaesthetics in cases where the heart is already so apt 
to be most seriously weakened. 

Mr. Owen speaks favorably of Macewen's method of performing osteot- 
omy above the condyles of the femur, and gives a very good illustration 
of its mechanical principles, yet, oddly enough, says that he prefers to do 
the operation from the outside of the limb, thereby entirely destroying 
the wedge shape of the osseous incision, upon which Macewen properly 



OWEN, SURGICAL DISEASES OF CHILDREN. 187 

lays much stress. This operation has grown into deserved popularity, 
and is so extensively adopted that we are glad to notice our author di- 
recting attention to the fact that it is not entirely without danger, and 
one which should not be lightly undertaken. He tells of one fatal case, 
occurring in his own practice, and mentions others which have resulted 
disastrously despite the most rigid Listerian precautions. While we have 
not been cognizant of deaths occurring, we have known very disagreeable 
effects to follow this operation, although we regard it as the most satis- 
factory form of osteotomy. 

Our author is disposed to look favorably upon the modern treatment 
of enlarged and degenerated glands, by removal or scraping, or when 
this is not possible on account of their relations and attachments, by their 
puncture with a red-hot needle. This treatment, so ably advocated by 
Treves, must commend itself to every one who has watched the tedious 
and unsatisfactory progress made under expectant treatment. 

In common with the majority of surgeons, Mr. Owen is an advocate 
of circumcision in very many cases, and much prefers a cutting opera- 
tion to stretching. We cannot help regarding the advice given as some- 
what extreme. Our experience leads us to think, with Willard, that the 
operation is not infrequently unnecessarily resorted to. Nor do we share 
the sentiment that stretching is always an ineffectual remedy. In very 
many cases we have found it to be all that is required, while it has the 
great advantage of being much less objectionable to parents than the 
more bloody operation, and it can very generally be done without the 
administration of an anesthetic. 

We have rarely read better condensed and practical directions for the 
performance of lithotomy than those given by Mr. Owen. He recom- 
mends a staff with a median groove, stopping short just where the beak 
curves off. The beak, he advises, should be short, so that the instrument 
can be used as a sound as well. Our author is very imperative in insist- 
ing that the bladder should be sounded and the stone felt just before the 
operation is begun, and urges that the incision should be sufficiently free 
to allow of the ready admission of the finger into the bladder, so as to do 
away with the risk of the bladder being pushed before the finger without 
its cavity being penetrated. We believe this last item of advice to be 
sound, while all practical surgeons concur in the propriety of the former. 
He does not think highly of the suprapubic operation, holding that it is 
impossible to improve upon the lateral lithotomy in childhood. Mr. 
Owen's remarks upon incontinence in children are excellent, showing 
the importance of careful study and gentle treatment in these often per- 
plexing cases. The scope of the work is so large that we could easily 
go on at length and pick out subjects to examine in detail, but we feel 
that we have done enough to convey to our readers some sense of the 
value of the book. 

Mr. Owen avoids trespassing upon the ground given up of late to 
specialists, and in this he is probably right, as his field is already suffi- 
ciently large ; but we confess that we should have liked to find something 
said about the more common forms of skin disease so frequently asso- 
ciated with the constitutional affections lying at the basis of so many of 
the ills the surgeon is compelled to treat. Then every surgeon who has 
had to do with institutions of which children are the inmates knows 
how troublesome are some of the forms of eczema, and, above all, of 
tinea. We should have been glad to find a sure and speedy method of 



188 KEVIEWS. 

treating this latter affection, which seems to us to be quite as worthy 
of discussion in a surgical work as molluscum contagiosum, an instance 
of which is made the subject of a colored lithograph. 

Mr. Owen writes agreeably and well, but he carries his modesty to an 
extreme. He has, apparently, a nervous dread of the personal pronoun, 
constantly saying, "one has seen," "one has heard," etc., which has a 
rather uncouth sound, while it diminishes the authority which attends 
the moderate use of the ego. Mr. Owen has written a good book, and 
might safely speak more often from the standpoint of his own observa- 
tion. But this personal peculiarity does not detract from the value of 
the work, which has no superior of the same size on the subject with 
which it deals. S. A. 



How to Drain a House. Practical Information for Householders. 
By George E. Waring, Jr., M. Inst. C. E., Consulting Engineer for 
Sanitary Drainage. 12mo. pp. 222. New York : Henry Holt & Co., 1885. 
London : Cassell & Co., Limited. 

As stated in the title, this book was written for the information of the 
individual householder, and contains a description of " the best way of 
improving the drainage of a human habitation, and of maintaining its 
good sanitary condition." The author remarks in his preface that the 
drains in average modern houses are probably the most serious and 
prevalent enemies with which struggling humanity has to contend.. 
They are, however, only incidentally enemies, never necessarily so. 

The intended purposes of drains are wholly beneficial. They very 
often fail of their object. But with all their defects they are a great 
improvement over the out-of-door privies, with all that their use implies. 
The drainage arrangements of a house are better than they were a few 
years ago, and the improvement is still going on. But the better pro- 
cesses are not generally adopted, mainly for the reason that they are 
not generally known, and therefore their value cannot be fully realized. 
The object of these pages is to furnish a simple and direct statement of 
some positive knowledge and of the author's opinions about the drain- 
age of a house, to enable the householder to comprehend thoroughly 
the importance of this vital element in house construction, and to adopt 
such processes only as have been proved to be reliable. 

The book is not a complex technical treatise, nor a prolix description 
of various systems and appliances, but rather an outline of what the 
author considers the best system of house-drainage. Such a selection, 
based on the results of a prolonged and fruitful experience, thorough 
technical knowledge, and clear judgment, is authoritative, and places 
the public in possession of a source of knowledge of great practical 
value in the experience of everyday life. 

In the first part of the book the author calls attention to the importance 
of draining the site of a house to prevent dampness, and points out 
practical methods of excluding moisture and ground-air by proper con- 
struction of subsoil drains, foundation walls, and cellar floors. In the 
construction of these drains the use of agricultural drain-tiles, of small 



WAKING, HOW TO DRAIN A HOUSE. 189 

size, say one inch and a quarter in diameter, is strongly advised, and, in 
order to hold the tiles in line and prevent the entrance of sand or 
silt, he recommends that the joints be wrapped twice around with strips 
of muslin, drawn tight. This plan has been found to yield most satis- 
factory results. He is opposed to the custom of connecting the under- 
drains of a house with the drain carrying foul water, and recommends 
an independent line in order to guard against the possible entrance of 
.sewage and foul air. 

From the seventh chapter to the close of the book, Mr. Waring 
gives his own views upon the subject of house-drainage, and states the 
grounds on which his opinions are based. The individuality of the 
book is its peculiar characteristic. The writer has had a large experi- 
ence in drainage Avork, the results of which he has sketched for the 
benefit of others. The object of the book would preclude a discussion 
-of the different methods of house-drainage, as well as the opinions and 
theories held by various writers, which would only tend to confuse the 
reader and detract from the usefulness of the book. The author frankly 
states wherein he holds opinions at variance with those commonly ac- 
cepted by most writers, and gives his reasons for such belief Apart 
from the disputed points, the book is a most admirable presentation of 
the latest and best knowledge upon the subject of house-drainage, well 
adapted to the wants of the people. 

Mr. Waring wisely recommends that the amount of plumbing work 
be reduced to the lowest convenient limit ; that the fixtures and pipes, so 
far as possible, be fully exposed to view, so as to be easily accessible ; 
.and that anything like complication in the waste-pipes be avoided. He 
would banish the wash-basin connected with the drainage system from 
the sleeping-room, and he would keep plumbing fixtures of any sort out 
•of the cellar of a house if possible to do so. 

Mr. Waring urge^ that all fixtures should be securely trapped, but 
<he is inclined to discard the main trap between the house and the 
public sewer. He recommends that " there should always be such a 
trap between the house and a flush-tank or a cesspool. I am inclined 
to the belief that there should not be such a trap in the case of discharge 
into a sewer, unless it be especially foul, If it is only a great cesspool, 
holding the accumulated deposits of a street or larger district, or if its 
interior atmosphere is at all comparable in ofFensiveness with that of a 
cesspool, then a trap will be desirable ; but if it has such an atmosphere 
as will admit of the entrance of workmen, and if its contents are carried 
forward in its current with reasonable completeness, I incline to the 
opinion that, even if no other house connected with it aids in its venti- 
lation, it will be better that the single house under consideration should 
be connected without a trap." The author deftly argues his point, and 
his proposition to omit the main trap might be accepted if it were not 
for the absence of the conditions upon which omission is justified. If 
sewers were in general well constructed, properly flushed, and well-ven- 
tilated, the use of a main trap might be dispensed with ; but, unfortu- 
nately, these important features of well-constructed and well-managed 
sewers are conspicuous by their absence from our present systems of 
sewerage, and, therefore, for the present it is far safer to adhere to the 
use of the intercepting trap, at least until sewers are constructed as they 
should be. 

Caps and ventilating cowls on the tops of soil-pipes, Mr. Waring 



190 REVIEWS. 

holds to be a positive disadvantage. He favors leaving the soil-pipe 
entirely open at the top, but protecting it from the accidental introduction 
of obstructing objects by inserting into the open mouth a spherical wire 
basket. In order to increase the movement of air, he advises an increase 
in the diameter of the single upper length of the soil-pipe. 

The difficulty of securing, in practice, the conditions upon which the 
successful use of the back ventilation of traps depends, has led Col. 
Waring to discard this device as useless in preventing the siphonage of 
traps. Another objection urged against this method is the increased 
facility which it affords for the evaporation of the water in the trap, and 
the greater liability to destruction of the seal. He, therefore, prefers to 
do away with the ventilation of traps, and use instead an antisiphonic 
trap of the kind invented by Mr. Putnam, which he considers the best 
trap thus far invented for wash-stands, bath-tubs, lavatories, etc. The 
description of Mr. Putnam's interesting and valuable experiments on 
the ventilation of traps, etc., merits a careful perusal. 

Mr. Waring inveighs against the too common practice of unnecessarily 
multiplying the number of fixtures in a house. Simplicity is the object 
to be aimed at, and this has also the advantage of economy. "While it 
is important to avoid unnecessary cost, the economical argument is the 
least of all the reasons for what is here proposed. The real and con- 
trolling argument is based on the great advantage of having the fewest 
possible points requiring inspection and care, and to secure the most fre- 
quent possible use of every inlet into the drainage system. Reasonable 
convenience being always kept in view, three water-closets in an ordinary 
house are much better than half a dozen ; and the same principle holds 
throughout the whole range of plumbing appliances." 

The author reasonably objects to the hidden overflow and the chain 
and plug in bath-tubs and washstands, as they soon become fouled. For 
the bath-tub he advises a return to the standing waste, which may also 
be adapted with advantage to the washstand. For the latter he remarks 
that the only really cleanly device that he has seen is what is known as 
" Weaver's Waste." The Dececo flush-pot for sinks is a handy device, 
which may be substituted, with benefit, for the troublesome grease-trap. 
The pan closet is properly classed among the worst forms of complicated 
water closets. Simplicity should be the controlling feature of these fix- 
tures. The hopper closets are the best of the cheap closets. Among 
the better class of closets, he describes the Dececo closet, an invention 
of his own, and he recommends it for use because it is perfectly suc- 
cessful in its working. It is without valve or moving part anywhere in 
the course of the outlet, objections which hold in the case of so many of 
the closets at present in use. 

To those who live in the country and in the smaller towns, Chapter 
XXV. will be especially interesting, as it treats of the subject of sewage 
disposal for isolated houses. Ordinarily, the cesspool is the makeshift 
for a better method of disposal. But it is no longer necessary that this 
dangerous nuisance should exist. An improved method of disposal has 
been carefully thought out and successfully applied, and it is well 
adapted to isolated houses which have at least a small area of land con- 
nected with them. It is the system of subsurface intermittent drainage, 
which automatically disposes of organic refuse and filth contained in 
liquid waste, in a hidden and inodorous manner, to the great benefit of 
the land. This system was started by the Rev. Henry Moule, and 



PARKER, CONGENITAL CLUB-FOOT. 191 

afterward modified and improved by Mr. Rogers Field, and finally 
perfected by Mr. Waring. It is now very successfully used by engi- 
neers in many parts of this country. The principle upon which this 
plan of disposal is based, and the method of its application, are fully 
described by Col. Waring in the concluding chapters of his book. 

We commend this excellent little volume to physicians, as well as to 
the public generally. It is a clear exposition of the leading principles 
of house-drainage. As already remarked, Mr. Waring differs on some 
points from the generality of writers on the subject, but he frankly states 
his reasons for such opposition. The book is well printed in large, clear 
type, upon good paper, is well bound, and makes an exceedingly neat 
volume. W. H. F. 



The Pathology and Etiology of Congenital Club-foot. By Robert 
William Parker, Surgeon to the East London Hospital for Children; 
and Samuel George Shattock, Curator of the Museum, St. Thomas's 
Hospital. Reprinted from the Transactions of the Pathological Society of 
London, 1884. 

Any researches which increase our knowledge of the etiology and 
pathology of congenital deformities, or tend to dispel the mystery which 
has heretofore surrounded them, are always most welcome. In the 
work now T noticed, the authors have assuredly made a step in the right 
direction, inasmuch as they have given the results of direct observation 
upon the embryo, and have, so far as possible, eliminated from their 
studies purely theoretical considerations. 

Up to the appearance of a paper by Dr. Henry W. Berg, of New York, 
of which we shall speak further, the existing theories of the causation 
of congenital talipes may be briefly summarized as, 1st. That which 
would ascribe the condition to pathological changes in the foetus, 
analogous to post-natal diseases. 2d. Heredity. 3d. Arrest of develop- 
ment. 4th. Abnormal intrauterine pressure and deficiency of amniotic 
fluid. All these have had their supporters, but do not rest upon any 
practical or scientific foundation, and Messrs. Parker and Shattock have, 
with good reason, discarded them. They adhere to a mechanical 
causation, the main facts of which are set forth in their introductory 
argument. They show that during intrauterine life the feet occupy 
different positions, to allow of proper development of the structures 
entering into their formation prior to birth, and normal position and 
range of motion to follow in consequence at birth. Anything interfering 
mechanically with this process, either by keeping the feet fixed or pre- 
venting the normal changes in position, will produce club-foot, the 
variety depending upon the nature of the force acting, and the period of 
foetal life at which it is applied ; the severity being in direct ratio to the 
violence of the mechanical cause in action. 

Whilst, to a certain extent, we agree with Messrs. Parker and Shat- 
tock in their conclusions, we are surprised that no allusion is made to 
the observations of Dr. Berg (" The Etiology of Congenital Equino- 
varus," Seguin's Archives of Medicine, Vol. VIII., No. 3, December, 1882. 
G. P. Putnam's Sons, New York), whose researches, made also directly 
upon the embryo, antedated the work under consideration over a year. 



192 EEVIEWS. 

In his article, Dr. Berg describes the changes in position of the lower 
extremities at different periods of foetal life, such changes being brought 
about by the normal rotation progressing in these parts. He shows that 
in early foetal life there is an outward rotation of the whole limb which 
is accompanied by an exaggerated varus, which is normal at this period, 
and later by an equino-varus, which diminishes as normal rotation pro- 
ceeds — any interference with this process is productive of congenital 
club-foot. 

The similarity of both the methods of investigation employed and the 
conclusions reached by Dr. Berg and the authors of the present work, is 
quite striking, the observations having been made in different parts ot 
the world by investigators acting wholly independent of each other. It 
seems, however, that the American contributor has carried his observa- 
tions a step in advance of the authors, and followed them to their legiti- 
mate logical conclusions, which, for some reason, Messrs. Parker and 
Shattock have avoided. As the latter state that they are still pursuing 
their investigations, and ask for any pathological material which will 
throw light upon it, we would respectfully call their attention to Dr. 
Bern's article. A. S. K. 



Moisture and Dryness ; or the Analysis of Atmospheric Humidi- 
ties IX THE UXITED STATES. An ESSAY READ BEFORE THE AMERICAN 

Climatologicat, Association in 1884. By Charles Denison, A.M., 
M.D., Professor of Diseases of the Chest and of Climatology, University oi 
Denver, etc. 8vo. pp. 30. Chicago : Rand, McNally & Co., 1885. 

This is an essay read before the American Climatological Association, 
in 1884, by Dr. Denison, whose investigations of the Climatology of the 
United States, and especially his observations of the meteorological 
characteristics of our far western territory, make him peculiarly well 
fitted to discuss the subject of climatic conditions as a therapeutic agent 
of practical value and application in the treatment of pulmonary dis- 
ease or weakness. 

The author starts out with the statement that dryness — that is, an 
actually small amount of atmospheric moisture — is a most important 
element in the best climates for phthisis. He then proceeds to the discus- 
sion of the subject of dryness in its various phases as a climatic attribute. 
A large amount of meteorological data is made use of in establishing his 
conclusions. These data are furnished by the U. S. Signal Service 
Bureau, and were collected at one hundred and thirty-six stations, cover- 
ing the whole territory of the United States. These statistics are 
arranged by seasons and are tabulated in convenient form. There are 
also eight colored weather charts prepared by the same bureau at the 
request of the author through the Colorado State Medical Society. The 
first four charts represent the mean cloudiness in tenths, zero being no 
clouds, for the whole United States ; the remaining four give for the 
seasons the absolute humidity (grains of vapor to the cubic foot of air) 
all over the United States. With the aid of these data the author en- 
deavors to show that the relative humidity alone is a delusive index of 



MOISTURE AND DRYNESS. 193 

dryness ; that the absolute humidity is a more important criterion. To 
use his own words : "A small number of grains of moisture to the cubic 
foot of air for a given temperature, is the most exact measure of the 
dryness of a given locality that we obtain from any one attribute of the 
atmosphere." 

Temperature and elevation, with distance from the sea, are powerful 
factors in the production of dryness. This is illustrated by the charts 
for absolute humidity. It is seen that during spring, summer, and 
autumn, much of Wyoming, Colorado, New Mexico, Arizona, and 
Nevada contain one-fourth in spring, one-third in summer, and about 
one-fifth in autumn, as much atmospheric vapor as Florida and the 
gulf coast of Texas, while in winter, owing to the lessened capacity of 
the air to hold moisture at low temperatures, there is not one-tenth the 
absolute humidity in the frozen atmosphere of the elevated, northern in- 
terior section of the country there is in the atmosphere of the gulf coast. 

The author takes issue with those who are in the habit of associating 
equability with the quality of dryness, and asserts most positively with 
the aid of statistics that variability is the distinguishing attribute of 
really dry places, while equability is, as a rule, characteristic of uni- 
formly damp places. By a natural sequence coldness, variability, and 
stimulation are arrayed against their opposites, warmth, equability, and 
enervation. According to this distinction, he proposes a division of 
climate under four heads, viz. : 

1. Excessive dryness | . . ^ ' h'l't 

2. Moderate dryness ] ° ta c ^ ' 

3. Moderate moisture | . . -, .-,., 

4. Excessive moisture j » ° ™ J' 

By means of a carefully elaborated rule of moisture and dryness, the 
various Signal Service Stations, one hundred and thirty-six in number, 
are rated according to this classification for the winter of 1883, with 
mean temperature added. A table is also prepared showing comparison 
of twenty-five dry with twenty-five moist localities, chosen from the whole 
number of stations. The former table is a very desirable one, as the in- 
valid needs a change of climate in the winter season, and its use will 
enable a choice to be made according to the requirements of the patient 
and the preference of the physician. 

The last few pages are devoted to a consideration of the physical 
effects of dryness on man. Real dryness, or low absolute humidity, favors 
increased evaporation from the skin and lungs, and it is reasonable to 
suppose that this increased transpiration of vapor is a means of effecting 
the escape of effete matter and wasted tissue, a circumstance which prob- 
ably has an important bearing on phthisis. 

In conclusion, attention is drawn to the climatic characteristics, especi- 
ally dryness, of the elevated interior of our continent, notably Colorado, 
as exerting a favorable influence on respiratory activity and on nutrition. 

Dr. Denison's essay is welcomed as a fresh contribution to the clima- 
tology of the United States. Some of his views may not be accepted 
without further evidence, but his investigations will stimulate inquiry and 
lead eventually to more correct notions of climate in its medical aspects. 

W. H. F. 

NO. CLXXXIIt. — JULY, 1836. 13 



194 REVIEWS. 



A Manual of Human Physiology, including Histology and Micro- 
scopical Anatomy, avith Special Reference to the Requirements 
of Practical Medicine. By Dr. L. Landois, Professor of Physiology 
and Director of the Physiological Institute, University of Griefswald. 
Translated from' the Fourth German Edition, with Additions by William 
Stirling, M.D., S.D., Regius Professor of the Institutes of Medicine or 
Physiology in the University of Aberdeen. Vol. I. with 176 illustrations, 
pp. 514. Vol. II. with 132 illustrations, pp. 670. London : Clay & Son. 
Philadelphia: P. Blakiston, Son & Co., 1885. 

The popularity upon the continent of Europe of this elaborate work, 
where, notwithstanding the variety of physiological handbooks dissemi- 
nated throughout the German Empire, four large editions have been 
demanded in the five years since it appeared, is justly a matter of sur- 
prise, and can scarcely be accounted for save on the ground, as asserted 
by the English translator, that in reality it forms a bridge between 
physiology and the practice of medicine, and constitutes a broad and 
firm highway from the study of natural healthy function to the accepted 
methods for rectifying disturbed and abnormal action in the diseased 
human organism. A careful examination of the work before us will, 
we think, convince any impartial reader, that the claim put forth by 
Dr. Stirling in favor of Prof. Landois is, at least so far as relates to 
the "eminent practicality" of his manual, a well-founded one. Ob- 
viously our author not only teaches his pupils how, and to what extent, 
pathological processes are derangements of normal activities, but also 
most effectively aids the busy physician to trace back from morbid 
phenomena the course of divergence from healthy physical operations, 
and to gather in this way new lights and novel indications for the com- 
prehension and scientific treatment of the maladies which he is called 
upon to cope with in his daily warfare against disease. 

In comparing the work of Dr. Landois with one of a standard English 
physiologist, such as that of the lamented Dr. Carpenter, we find, for 
example, in the section devoted to the " Urinary Secretion," that with 
the admirable additions appended by Dr. Stirling, the histology of the 
kidney is explained at much greater length, and with a more generous 
profuseness of illustration. The ordinary and abnormal constituents of 
the urine are very elaborately discussed, and the various urinary sedi- 
ments are described and depicted with superior minuteness, instead of 
being dismissed with a concise, verbal account, as in Dr. Carpenter's 
w T ork. On the other hand, however, this last mentioned handbook offers 
us more detailed investigations in regard to the functional activity of 
the renal organs during health, and concerning the modus operandi of 
production for sundry abnormal ingredients of the renal secretion, as 
manifested in different diseases of the kidneys. Still, Dr. Landois's brief 
but lucid exposition of the mechanism involved in " Retention and In- 
continence of Urine," printed in such small type that but little space is 
occupied, carries out the alluring promise of the preface, in regard to 
bridging over the gulf between physiological and medical science. The 
superiority of the German work is attractively displayed in the abundant 
illustration allotted to this portion of the volume, renal anatomy being 
elucidated by no less than seven figures, including four of Prof. Tyson's 



MAY, DISEASES OF WOMEN. 195 

improved modifications of Klein's, and of Henle's pictures. The micro- 
scopical characters of all the common, and several unusual urinary 
deposits, are given in twenty-eight woodcuts, most of which are truthful 
and artistic, although the representations of tube-casts in Bright's disease 
are far from perfect, and that of sarcina is totally incorrect and mis- 
leading. 

An additional feature of great practical value is exhibited in the 
condensed account of the " Comparative Physiology of the Urinary 
Apparatus," and in the brief historical resume devoted to an outline 
sketch of the chief discoveries relating to the kidneys, from the days of 
Aristotle to the present time. Such a narrative of the progress of our 
knowledge in regard to the renal functions, not only serves to gratify a 
legitimate curiosity, which often forms a powerful incentive to the prose- 
cution of diligent study, but also contributes in an agreeable manner 
to fix indelibly in the mind of a student the essential facts and many 
minor details of renal physiology and pathology. 

In the labor of translation, Dr. Stirling states that he has endeavored 
throughout to convey the author's meaning accurately, without a too 
rigid adherence to the original. If, as we are told, the musical Italian 
tongue ought always to be written upon satin, German frequently appears 
harsh enough to be inscribed only upon sandpaper, and this rugged 
character of the language is too often manifested in English translations, 
where many of the unpolished and obscure Teutonic idioms are retained. 
Dr. Stirling has, however, presented the author's thoughts in a smooth 
and flowing English dress, and the shortcomings, for which he apologizes, 
are so few and unobtrusive, that any reader who knows by experience 
the difficulties of his undertaking, will pardon these insignificant failures 
almost before any plea for forgiveness has been offered. 

J. G. R. 



Manual of the Diseases of Women, being a Concise and Systematic 
Exposition of the Theory and Practice of Gynecology : for the 
Use of Students and Practitioners. By Charles H. May, M.D., 
late House Physician to Mount Sinai Hospital New York, etc. Phila- 
delphia: Lea Brothers & Co., 1885. London : Cassel & Co., Limited. 

This small volume of 350 pages was prepared by its author, as he 
says in the preface, in answer to the request of his quiz classes, and is 
"intended to aid the student, who, after having carefully perused larger 
works, desires to review the subject ; and it may also be useful to the 
practitioner who wishes to refresh his memory rapidly, but has not the 
time to consult larger works." He claims no originality for his state- 
ments, but has compiled them from " the writings of Emmet, Thomas, 
Munde, Simpson, Barnes, Playfair, Duncan, Hart and Barbour, Hewitt, 
Tait, Schroder, Fritsch, and the lectures of Professor McLane and Dr. 
Tuttle, of the College of Physicians and Surgeons, New York." The 
work departs somewhat from the ordinary range of manuals, being, in 
fact, a syllabus, with occasional elaboration of the more important sub- 
jects, and embracing in small compass a vast array of heads or memo- 
randa, to remind the reader of the associated symptoms, conditions, and 



196 EEVIEWS. 

diseases, with their resemblances, which are to be considered in making 
a proper or differential diagnosis in any given case. Such a book cannot 
take the place of the more elaborate treatises on gynecology, but it may 
be of value in leading to a careful research for definite facts and clinical 
records regarding matters perhaps little known to or investigated by the 
reader. We also can see where it would be of value to a lecturer, as an 
indicator of the subjects upon which he ought to instruct his classes, and 
may lead to a wider field of investigation and study on his part. In 
the chapter upon ovariotomy we could suggest several improvements in 
the peritoneal toilet, closure of the abdominal wound, its dressing, etc. ; 
but these are matters of opinion, and subject to frequent changes, based 
upon individual success. Too little attention is being paid to closing 
the abdominal wound, so as to leave the least unsightly cicatrix, and 
dressing it, to avoid the suppuration of the suture holes. The best suture 
we have seen is fishing snood, three stitches to an inch, well shotted, and 
so inserted as to take in the parts widely on the peritoneal side, and 
leaving but little skin between the exit ends under the shot. The best 
dressing is Keith's new one, of one part of carbolic acid to eight of glyce- 
rine, applied over the wound upon absorbent cotton ; this makes a dry 
wound, the parts healing without suppuration. 

Under the head of " Extraction by Laparotomy," the author does not 
indicate the great danger of removing a living ectopic foetus when near 
or at maturity. This should be forcibly impressed upon the mind of 
every one who has under care a case of abdominal pregnancy with a 
maturing foetus, 

Dr. May's work is in good, clear type, and will, no doubt, prove attrac- 
tive to medical students. It is far better than any medical catechism 
could be. R. P. H. 



De la Suture des Nerfs a Distance. Par le Dr. George Assaky, 
Preparateur de Medecine Operatoire a la Faculte, etc. 8vo. pp. 80. Paris : 
Asselin et Houzeau, 1886. 

The Suture of Nerves after Loss of Substance. By Dr. George 
Assaky, etc. 

It is not easy to translate smoothly the title to this interesting mono- 
graph, but it may doubtless be gathered from the expression we have 
chosen to stand for suture a distance, that the author discusses the sub- 
ject of attempting to unite by suture the divided end of nerves, from 
which a certain part has been removed. His whole work depends 
upon the well-established fact, that the nerves are capable of exten- 
sion without solution of continuity, and that this extension is followed 
by retraction, when the extending force is removed. He has taken 
pains to study this property of the nerves, both anatomically and ex- 
perimentally. It appears that the elasticity of a nerve resides in the 
interlacing fibres of the neurilemma (of Bichat), or perineurium (of 
Robin). The remaining portions of the nerve appear to be passive, 
being smooth when it is extended, but exhibiting cross-markings 
(wrinkles?) when the nerve is relaxed. The extensibility of a nerve is 
also limited by certain extraneous connections. Thus the proximal portion 



197 

of a divided nerve can be extended downward more than the distal portion 
can be drawn upward. This is due to the restraining influence of the 
branches of the nerve which furnish so many anchors attached below, 
while branches situated above, do not offer any resistance to a force 
tending to draw the nerve downward. 

The author gives a good and detailed account of the experiments he 
performed in a number of lower animals, to determine the effect of 
drawing parts of a nerve together over a gap, using for his suture cat- 
gut, fragments of tendon, a piece of a trachea, a strip of muscle, and a 
strand of silk thread. In all the experiments the material served as a 
sort of scaffold or guiding thread for the prolongations of newly forming 
nerve substance tissue. 

Next he considers the different methods thus far proposed with the 
object of bridging a gap in a divided nerve. These are: 1. Grafting a 
portion of nerve from another animal of the same or of another species. 
2. Grafting the peripheral end into a neighboring intact nerve. 3. 
Uniting the lower end of one nerve to the upper end of another simul- 
taneously divided. 4. Union of flaps dissected up from the opposite 
ends of the divided nerve. 5. Tubular suture. It is hardly worth 
while to sketch the argument of our author in regard to the respective 
merits of these different methods. It is enough to state that his views 
are consistent with the present general verdict of experimenters and 
students, that no living or dead tissue, whether from the body of another 
subject or from that of the same one, introduced between the opposite 
ends of a divided nerve, ever serves as anything more than a scaffolding 
or guiding thread, along which the budding prolongations from the 
proximal end can travel. As to the method of suture called a distance, 
by which an attempt is made to approximate the more or less remote 
ends of a divided nerve, his conclusions are reasonable, and, we think, 
admissible, viz. : That suture of nerves after loss of substance may be of 
real service; that experiment upon animals shows that it hastens the 
regeneration of a nerve, by diminishing the interval which separates the 
ends, while the cicatricial tissue along the threads of the sutures is 
richer in newly formed nerve fibres than when the cure is left to nature 
alone. 

It will be observed that these conclusions are not at all startling, but 
it may be worth all the care and labor the author has devoted to the 
subject, to have called attention to the reasonableness of making use for 
the repair of nerves, of that property which has so often been utilized in 
the operation of nerve-stretching. C. W. D. 



The Principles and Practice of Surgery. By Frank Hastings 
Hamilton, A.M., M.D., LL.D. Third edition, revised and corrected. 
8vo. pp. xxxii. 989. New York : William Wood & Co., 1886. 

The eminence of the author of this volume must secure for it many 
readers, while the vast experience of which it is the outcome, gives 
weight and value to every statement of opinion which it contains. In- 
deed, it is as a record of personal observation that it will be chiefly 



198 REVIEWS. 

esteemed, for in these days a thoroughly satisfactory treatise upon so 
enormous a subject as surgery, can hardly be constructed within the 
narrow limits which Dr. Hamilton has allowed himself. For many 
years he has been an acknowledged authority upon any surgical subject 
of which he treats, and the ability, accuracy of observation, and acute 
reflective powers which have made him such, will cause every thought- 
ful and progressive surgeon to give careful consideration to any estimate 
he places upon new methods and highly vaunted plans of treatment. 

Dr. Hamilton writes with much vigor, and it is never hard to under- 
stand his meaning. He does not hesitate to condemn lines of practice 
with which he is not in accord, and sometimes in no measured terms, 
fearlessly arraigning in some cases the honesty, in some cases the ignor- 
ance that he thinks supply too much of the basis upon which some 
methods rest. The reader will sometimes think there is rather too much 
heat shown for the matter in hand, and wonder at the impetuosity of 
the writer; yet Dr. Hamilton does not transcend the limits allowed by 
courtesy. Indeed, we confess to surprise that he has not sometimes gone 
further. Thus, he narrates the history of the case of President Garfield, 
clearly and succinctly, but he has not descended to the level of replying 
to the extraordinary and presumptuous attacks made upon the treat- 
ment there adopted. 

The book is intensely practical, dealing more largely with treatment 
than with pathology, and it has been revised with care. As a con- 
sequence, it contains the conclusions to which its author has come after 
full experience with many of the most recently suggested plans of treat- 
ment. Yet some of these he has passed over in silence. Thus we have 
looked in vain for an expression of opinion concerning the resort to 
trephining upon the basis of cerebral localization, though he speaks 
freely of that operation undertaken to fulfil other indications. Neither 
does Dr. Hamilton take any notice of paracentesis pericardii. Are we 
to argue from this, that our author does not regard either operation as 
justifiable? 

The book is divided into two parts, dealing with general and regional 
surgery, and while both are well treated, the latter will be found the 
most interesting, as well as the most valuable. But nowhere is there a 
lack of interest. In view of its author's cultured ability, and from the 
fact that his personality is impressed upon every page, it could not well 
be otherwise. 

It is a pleasure to see so good and experienced a surgeon occupy the 
conservative position which Dr. Hamilton almost always does. 'I hat he 
is not timid is abundantly evidenced by many cases recorded in these 
pages, but that his experience has led him to question the advantage to 
the patient of many operations glibly proposed and fearlessly under- 
taken of late years, is equally evident. His opinion upon modern anti- 
septic methods is well known, and his concluding chapter is devoted to 
a consideration of primary union, and the value of antiseptics in wounds 
generally. This chapter is especially worthy of study. Dr. Hamilton 
thinks that many failures to obtain speedy union in amputations and 
other deep wounds involving the muscles, is partly owing to the indiffer- 
ence, and even roughness, with which they are treated while the patient 
is under the influence of an anaesthetic. He gives full credit to the 
beneficial effect of the Listerian doctrines, but attributes the good results 
obtained to the care and gentleness with which the dressings are applied, 



VON ZIEMSSEN, GENERAL THERAPEUTICS. 199 

and the free drainage provided, rather than to any direct influence of 
carbolic acid or bichloride solutions in antagonizing the presence of 
germs. This view is temperately stated, and fortified by thoughtful, 
judicious arguments. 

We have looked upon this book as too well known to require ex- 
tended analytical examination, and have only spoken of it in very 
general terms. It will be enough therefore, if we conclude this brief 
notice by saying that the student of surgery need have no hesitation in 
committing himself unreservedly to any treatment which its author ad- 
vises, for that advice is always sound, judicious, and worthy of every 
confidence. S. A. 



Yon Ziemssen's Handbook of General Thebapeutics, Vol. IV. The 
Treatment of Disease by Climate, by Dr. Hermann Webeb ; trans- 
lated by Heinrich Post, M.D., M.E.C.P. Lond., Physician to the Ger- 
man Hospital, London, etc. : and General Balneotherapeutics, by 
Professor Otto Leichtenstern ; translated by John MacPherson, 
M.D., Inspector-General of Hospitals (retired). Pp. 496. New York: 
William Wood & Co., 1885. 

As admitted by the translator of the first department of this valuable 
work, the complete and exhaustive treatise on its subject has yet to be 
written, and will probably, when produced, prove the ripe fruit of re- 
searches carried on by many co-laborers in this fruitful field of sanitary 
science. Hence, although Dr. Weber's experience as a climatologist 
renders him peculiarly fitted to take his place as a contributor to such a 
systematic work upon the resources of climate in our endless struggle 
against disease, the English and American reader must expect to find 
many important questions, about which he turns to these pages for prac- 
tical instruction and guidance, but briefly touched upon, or, it may be, 
entirely overlooked. 

But whilst the list of sins of omission is somewhat extended, we take 
pleasure in saying, that the faults of commission are few and trivial in 
comparison. 

Dr. Weber claims for his countryman von Humboldt, the honor of 
founding recent climatology, which, he declares, is yet in its infancy, 
and capable of a high degree of development, which will vastly increase 
its power as a remedial and prophylactic influence in nearly all derange- 
ments of human health. In dealing with the extensive array of observa- 
tions in regard to climate, which has already accumulated, our author's 
plan is to consider first the different elements or factors of climate, and 
their more important modifying influences; second, to attempt a classi- 
fication of the various climates, furnishing under each head a short 
account of the regions and places suitable for the treatment of invalids; 
third, to indicate what benefits may be expected from these respective 
climates in certain pathological conditions, or simple morbid tendencies, 
where actual derangement of health has not yet occurred; and lastly, to 
point out methods of instituting a combined system of climatic and 
hygienic treatment, without sending the patient far away from home, 
home comforts, and the sympathy of relatives and friends which, per- 



200 REVIEWS. 

haps, can alone render life enjoyable enough to stimulate the invalid to 
the point of carrying on the needful struggle for regaining health. 

In the generally complete summary of our knowledge respecting the 
elements which enter into the complex idea of climate, we are surprised 
to find no reference, under the head of electricity, to the interesting re- 
searches published some years since by Dr. S. Weir Mitchell, which 
indicate that a belt of electrical disturbance surrounds and travels with 
areas of low barometer or storm centres, exciting attacks of neuralgia 
in patients predisposed to this malady. Such an omission is the more 
remarkable in view of the fact, that Dr. Weber states that " the physi- 
ological and pathological effects from variations in atmospheric elec- 
tricity are probably of great importance." 

The marine climates are subdivided by our author into, first, those 
with a high degree of humidity, such as Madeira, the Azores, the Sand- 
wich Islands, and the West Indies ; second, those with a medium degree 
of humidity, among which are classified the Mediterranean ports, and 
in the subgroup of cool moderately humid localities, the various resorts 
upon the British coasts ; third, the western Riviera, Cannes, Nice, the 
south of Africa, Australia, etc., which make up the class of marine 
climates with a low degree of humidity. 

In discussing the various considerations which influence our choice of 
climate in particular diseases, Dr. Weber classifies the different forms of 
phthisis in thirteen groups, specifying the appropriate resorts for most of 
these in such a way as to render his remarks practically useful. Under 
the head of prophylactic treatment of the phthisical tendency, he men- 
tions the instructive case of four children, coming from a thoroughly con- 
sumptive stock, the father and mother (also of phthisical descent) having 
died of phthisis before reaching the age of thirty, and two elder children 
falling victims to catarrhal pneumonia before the period of puberty. By 
proper management, such as he points out, at certain of the English coast 
stations, these four have all grown up well developed, being now be- 
tween tw T enty-five and thirty years old, and in the enjoyment of excellent 
health. 

In his short chapter upon home climatic treatment, which is so con- 
cise as to be disappointing in its brevity, Dr. Weber contends that by 
making suitable alterations in a patient's habits, mode of life, and so 
forth, many of the advantages possessed by far distant sanataria may 
be gained for those invalids who are unable, on account of the cost, or 
for other reasons, to migrate to foreign health resorts. 

In the second portion of the work, Prof Lei chtenstern has endeavored 
chiefly to lay down the great principles of balneotherapeutics, without 
in general formulating detailed rules for the application of various kinds 
of baths as curative measures. The author first considers at some length 
the action of baths at or near the normal temperature of the body, the 
so-called thermally indifferent baths, and then those above and below 
98.4° F. ; these effects being described as influencing the change of tis- 
sue, and of the excretions, as affecting the circulation and respiration, 
the nervous system, not forgetting the electrical and the mechanical 
effects. 

The baths themselves as regards their pharmaco-dynamic and thera- 
peutic efficacy, are next described, being arranged in the groups of the 
simple acidulous, the alkaline, the bitter, the culinary salt, the sea 
baths, the iron, sulphur, and lime-containing waters. Lastly, about 



KICHARDS, SNAKE POISON LITERATURE. 201 

thirty pages are devoted to a synopsis of the empirical indications of 
different drinking and bathing " cures " in individual diseases. An ap- 
pendix necessary to render this valuable work more complete, gives 
some account of peat and slime, pine leaf and herb, sand, bark, mustard, 
malt, and bran baths, and also of the whey, koumiss, and grape cures. 

Prof. Leichtenstern maintains that artificial saline waters, prepared 
in imitation of the natural ones, and used by bathing and drinking, as 
these are in the celebrated " cures," such as Carlsbad, which is so famous 
all over the world, may be rendered quite equal to those of the original 
springs, in their therapeutic action. Further advantages are to be found 
in the facts, that these imitations are much cheaper than the exported min- 
eral waters, and that they do not contain " a useless ballast of inoperative 
or injurious constituents, such as gypsum, silica, alumina, and so forth." 
As to the belief in a wonderful and mysterious efficacy of the natural 
waters, current in certain medical circles and among the laity, he frankly 
admits that it does not seem to be even founded upon fact. If sufficient 
care is taken to secure unpolluted water, absolute purity of the chemi- 
cals, and chemical apparatus, and accuracy in the quantities of the in- 
gredients, trustworthy preparations will result, and such artificial Seltzer 
water as that produced by Struve, and the Apollinaris furnished by 
Ewich, are in his opinion quite reliable. An artificial Carlsbad water 
which our author has used largely in his ow T n .practice, and prefers to 
that prepared with the famous Sprudel salt, is composed of crystallized 
sulphate of sodium, fifty parts, bicarbonate of sodium, twenty parts, and 
chloride of sodium, ten parts. When it is important to increase the 
peristaltic action, a larger proportion of the Glauber salts may be 
ordered. 

The last chapter, which is devoted to employment of drinking and 
bathing cares in particular diseases, is full of practical suggestions, some 
of which we would be glad to lay before our readers did space permit. 

J. G. R. 



The Landmarks of Snake Poison Literature, being a Eeview of 
the More Important Eesearches into the Nature of Snake 
Poisons. By Vincent Richards, F.E.C.S. Ed., etc., Civil Medical 
Officer of Goalundo, Bengal ; late member of the Indian Snake Poison 
Commission. Calcutta: 1885. 

The author of this most interesting little book is, we believe, well 
known in India as a physician of distinction, and as a member of a 
former government commission which notably advanced our knowledge 
of snake poisons. It is a book which would be attractive to lay readers, 
but has the better purpose of clearly saying what is and what is not 
known as to venoms, so as to prevent loose and useless future research. 
To read it might save us from propositions like that in a recent number 
of the Lancet, to treat hydrophobia by snake poison, a thing which, 
strange as it may seem, has already been tried by Sapolini, of Italy, 
and failed. Mr. Richards gives us startling accounts of the deaths in 
India from venom. He then considers the whole history of research as 
regards venom down to the latest papers, but does not include all of 



202 REVIEWS. 

Lacerda's more striking conclusions. So, also, lie fails to report Dr. 
Mitchell's paper on the "Mechanism of the Capillary Hemorrhages." 
The complete research by Drs. Mitchell and Reichert, which was par- 
tially announced in their preliminary report in The Medical News of 
April 28, 1883, will probably be the greatest advance this subject has 
made ; it is about to appear as one of the " Smithsonian Contributions." 

What is now wanted is a more complete study of Indian venoms by 
a government commission, including physiologists and chemists, to be 
controlled by some acute observer like the author of this excellent book. 

In this country snake poisoning has become very rare, and the ser- 
pent-slaying hog has saved us many lives. Superstition, as in favor of 
the snake, prevents his destruction in India, and the Eastern antipathy 
to the hog perhaps interferes with the availability of this valuable 
exterminator of poisonous reptiles. The volume bears a dedication to 
Dr. Weir Mitchell. G. H. 



Health Reports. 

1. Seventh Annual Report of the State Board of Health of 
Illinois, with an Appendix Containing the Sanitary Publica- 
tions of the Board during 1884. 8vo. pp. 613. Springfield: 1885. 

2. Proceedings and Addresses at the Sanitary Convention held 
at Ypsilanti, Michigan, June 30 and July 1, 1885. 8vo. pp. 173. 
Lansing: 1886. 

3. Ninth Report of the State Board of Health of Wisconsin 
for 1885. 8vo. pp. 308. Madison : 1886. 

1. The prominent features of the Illinois Health Board's work during 
the past year, have been the continued progress in the improvement of 
medical education, and the preparation to resist the importation of Asiatic 
cholera. As a result of the stand taken by the Board of Health, we find 
that there are now one hundred and ten colleges in the United States 
and Canada (out of a total of two hundred and thirty-three) which insist 
on an educational requirement as a condition for graduation, against 
forty-five that were thus exacting when this movement in favor of a 
higher standard of medical education was first originated about six 
years since. Attendance on three or more lecture courses is now com- 
pulsory in thirty-six colleges, and provision is made in forty-five others 
for a three or four years graded course. Hygiene is taught in ninety- 
one, and medical jurisprudence in ninety-seven institutions for medical 
education, whilst seven more colleges have lengthened their lecture 
terms to five months or over, and ten have prolonged their sessions to 
six months or over since the issuance of the last report. 

2. The proceedings of the Ypsilanti Sanitary Convention are made 
up of about twenty interesting essays, several of them models in their 
way, and admirably calculated to awaken the people of southeastern 
Michigan to the inestimable value to themselves and their children of 
faithful hygienic work. Among the important questions considered, 
were the sanitary conditions and needs of school buildings and grounds, 
by Prof. Austin George ; the prevention of communicable diseases, by 



MOUKE, DISEASES OF THE NASAL FOSSA. 203 

O. W. Wright, M.D., the well-known health officer of Detroit; the 
sources of malaria, and the past, present, and future water-supply of 
Ypsilanti, by various writers, and an extended address on the influence 
of sewerage and water-supply on the death-rate in cities, by Irwin F. 
Smith, of Ann Arbor. This essay is a well-written and cogent plea in 
favor of a proper system of sewers, the author maintaining that the 
general death-rate falls after the sewering of a city, and, other things 
being equal, never again reaches its previous maximum. 

3. From Wisconsin, we learn that the year ending Oct. 31, 1885, 
has been remarkably free from any extensive outbreaks of contagious 
disease, and, what is an almost equally worthy cause of self-congratula- 
tion, that a decided advance in favor of public hygiene throughout the 
community is apparent. Nevertheless, it would seem that ample room 
for improvement, especially in the outlying rural districts still remains, 
as, for example, was shown in the case of an outbreak of diphtheria in 
the city of Eau Claire, where the School Board at first resisted the 
order of the Health Board to close certain of the public schools, and gave 
notice that they would all be open as usual. The Board of Health, 
however, maintained its ground, and in the conflict of authority thus 
inaugurated was fully sustained by the courts. 

Preparations were made throughout the State to prevent the intro- 
duction of cholera, and circulars containing the requisite information 
were published and very widely distributed among the citizens of Wis- 
consin. The same precautions, which fortunately proved needless for 
the summer during which they were first urged upon the people, are 
judiciously advocated again for this season, when the early activity of 
the pestilence in Italy, and certain other portions of the Mediterranean 
coast, appears to threaten renewed danger to the United States. 

The volume is almost entirely made up of reports from local health 
boards, without any essays upon the sanitary problems of the day. A 
brief special report from the State Veterinarian mentions that glanders 
has been found to exist in fourteen counties, and that forty-one horses 
have been killed in order to limit its ravages. Only one instance of 
inoculation of this disease upon a human being in Wisconsin during the 
past year is recorded. Anthrax and tuberculosis in cattle, swine plague 
or " hog cholera " among pigs, and a cattle disease resembling ergotism, 
have made their appearance, but have been prevented by suitable sani- 
tary precaution, from inflicting any serious ravage, up to date of publi- 
cation of the report. J. G. R. 



Manuel Pratique des Maladies des Fosses Nasales et de la Cavite 
Naso-pharyxgienne. Avec 53 figures dans le texte et 4 planches en 
lithographie, hors texte. Par le Dr. E. J. Moure, Professeur libre des 
Maladies du Larynx, des Oreilles et du Nez ; Directeur de la Eevue Men- 
suelle de Laryngologie, Otologic et Ehinologie, etc. 12mo. pp. 304. Paris: 
Octave Doin, 1886. 

A clearly written, comprehensive, and well-arranged manual of 
diseases of the nose, eminently practical, and, in the main, Avell abreast 
with the present advancement of rhinology. While dealing cleverly with 



204 REVIEWS. 

the subjects usually treated under this head, it has, besides, especially 
interesting chapters upon Abscess, Tuberculosis, Dermatoses, and Neu- 
roses of Sensibility of the Nasal Fossae. 

Were we to criticise the work, it would be to suggest that the recog- 
nition of certain American methods of treatment, as, for instance, the 
employment of chloroform or ether in the removal of living parasites 
from the nasal cavities, and the use, in its many and varied applications, of 
Jarvis's snare ecraseur, an instrument decidedly superior to any figured 
in the book. An account of the several operations now successfully em- 
ployed here for the correction of deflections of the nasal septum, etc., 
would have added materially to its usefulness. These, however, are 
minor considerations amid so much which is to be commended, and the 
book will be read with interest and profit by those for whom it is in- 
tended. D. B. D. 



Clinical Studies on Diseases of the Eye, including those of the 
Conjunctiva, Cornea, Sclerotic, Iris, and Ciliary Body. By Dr. 
Ferdinand Bitter von Arlt, Professor of Ophthalmology in Vienna. 
Translated by Lyman Ware, M.D., of Chicago. 8vo. pp. 325. Philadel- 
phia : P. Blakiston, Son & Co., 1885. 

Upon the view that inflammation, wherever found, is to be combated 
upon certain general principles, almost all medical men are ready to 
undertake the treatment of the " common inflammations " of the eye." 
Whatever of fallacy there may be in such a view, and whatever of risk 
there is in such an undertaking, is revealed by the perusal of a work like 
this. The author's purpose has been " primarily to give the physicians 
engaged in general practice a book of reference which they could consult 
regarding the common and most frequent diseases of the eye." A worthy 
object ! But, we fear, followed with self-defeating zeal. For only special 
interest, or a very unusual desire for thoroughness, will lead one to give 
this treatise, of three hundred and twenty well-filled octavo pages, the 
attention it deserves. He who does give it such consideration, however, 
can hardly fail to thank author and translator for their thorough work. 

Clinical study is, of course, something very different from book-making, 
or book-using ; yet, in the sense in which a book may bear such a title, 
this one deserves it, revealing, as it does, the w T ealth of the clinical expe- 
rience of the author, and constituting an accurate and most suggestive 
guide to the clinical studies of the reader. It contains little that is 
entirely new to ophthalmic science, but gives a most complete resume of 
our present knowledge, full justice being done to subjects of such recent 
interest as vernal conjunctivitis, and the use of the actual cautery in 
corneal abscess. It does not grapple with pathogenic bacteria ; and 
the translator has found it worth while to interject brief allusions to the 
uses of jequirity and cocaine. The book is practically destitute of illus- 
trations, has a fair supply of foot-notes and references, and in press work 
bears the stamp of Philadelphia excellence. It is a volume which will 
prove a valuable addition to the working library of the thorough 
ophthalmic surgeon. E. J. 



QUARTERLY SUMMARY 



PEOGEESS OF MEDICAL SCIENCE 



ANATOMY. 



UNDER THE CHARGE OF 

GEORGE D. THANE, M.E.C.S. Eng., 

PROFESSOR OF ANATOMY AT UNIVERSITY COLLEGE, LONDON. 



The Lumbar Curve of the Spine in Several Eaces of Men. 
The characteristic lumbar curvature of the human spine is the result of 
the conformation of the vertebral bodies and of the intervertebral disks. 
The degree of curvature can only be ascertained with precision by measure- 
ments carried out on sections of frozen bodies ; but in the absence of fresh 
subjects of different races, some indications may be obtained by comparing 
the relative depth of the vertebral bodies in front and behind. Sir William 
Turner finds that in Europeans the first and second lumbar vertebrae are 
generally thicker behind than in front; that in the third and fourth the 
bodies are generally deeper in front ; and that the fifth is always characterized 
by a greater proportional anterior depth. In negroes, Andamanese, and 
especially Australians, the upper lumbar vertebrae show a greater preponder- 
ance of the posterior vertical diameter, while the fourth and fifth are relatively 
shallower in front, so that, unless the differences in the form of the bones are 
neutralized by the disks, the lumbar spine is less curved in those races. To 
express the relation of the anterior and posterior depths, a lumbar index is 
calculated, the anterior vertical diameter being taken as the standard — 100. 
The average index of the five lumbar vertebrae in 12 Europeans is 95; in 2 
Esquimaux, 98.3; in 2 Lapps, 98.3; in 3 negroes, 98.9; in 2 Andamanese, 99; 
in 2 Sandwich Islanders, 104.7; and in 5 Australians, 105.8. The lowest 
index met with is 84.8, in a Chinese skeleton, and the highest 106, in a Bush- 
man. One Malay skeleton gives an index of 98, and one Maori 100. Spines 
with a lumbar index are termed koilo-rachie; those with an index from 102 
to 98, both inclusive, are ortho-rachie; and those with an index below 98 are 
Jcurto-rachie. — Journal of Anatomy and Physiology, April, 1886. 

On the Morphology of the Tarsus. 
The development of the astragalus, and the significance of the ossicle termed 
"by Bardeleben os trigonmn, are discussed by G. Baur in the January number 



206 PROGEESS OF MEDICAL SCIENCE. 

of Gegcnbaur's Morphologisches Jahrbuch. After a critical analysis of the 
literature relating to this subject, the author gives a summary of his own 
observations. The ossicle in question is present in many marsupials, but it 
does not occur normally in the monotremata, nor in any of the eutheria, in 
all of which the astragalus is developed from a single cartilage. The division 
of the cartilaginous astragalus in the human fetus described by Bardeleben 
does not exist. Baur regards the supernumerary ossicle occasionally found in 
man at the back of the astragalus as the homologue of the os trigonum of 
marsupials, and considers it probable that a similar ossicle may occur as a 
variety in other mammals, but that it has not yet been recognized, owing to 
the relatively small number of individuals examined. He doubts the cor- 
rectness of Bardeleben's view that the os trigonum is the intermedium tarsi, 
being inclined rather to regard it as a sesamoid bone, and not as a typical 
tarsal element, since it appears to be developed in marsupials later than the 
true tarsal bones. The so-called tibial sesamoid bone would then be the 
tibiale, and the astragalus, which, being developed from a single cartilage, 
represents only one element, would be the intermedium. 

On the Condition of the Umbilical Vein after Birth, and its 

Anastomoses with the Veins of the Abdominal Wall. 

E. Wertheimer confirms the statement of Baumgarten that in a majority 
of cases there is a small vein in the centre of the round ligament of the liver 
in the hepatic part of its extent, but regards this as a newly formed vessel, 
and not as a persistent portion of the umbilical vein. In the infant the 
lumen of the umbilical vein speedily becomes closed by a plug of connective 
tissue, and this plug is subsequently excavated by the central vein, for which 
the designation centro-umbilical is proposed, and which is continuous with 
similar small veins in the peripheral part of the round ligament. The 
centro-umbilical vein opens above into the left branch of the portal vein, 
either directly or by the intervention of the upper end of the umbilical vein, 
which, as observed by Sappey, may remain pervious for a distance of one or 
two centimetres. 

In two fetuses, and in five out of eleven infants, Wertheimer found a 
vestige of the venous network of the abdominal wall which opens into the 
allantoic veins in early fetal life, in the form of a small vessel connecting 
the umbilical and epigastric veins, similar to that described by Burow, but 
he believes that this communication is not present as a rule at the time of 
birth, and that when so it subsequently becomes obliterated with the umbili- 
cal vein. In certain rare cases of anomaly, such as those described by Monro, 
Meniere, Manec, Klob, and others, the umbilical vein and its communication 
with the epigastric remain patent, giving rise to a channel uniting the portal 
and iliac veins, homologous with the anterior abdominal vein Of batrachians. 
— Journal de VAnatomie et de la Physiologie, February, 1886. 

On the Rudiment of a Septal Gland in the Human Nose. 

The tubular recess at the lower and forepart of the nasal septum of man 
is commonly regarded as a rudiment of the organ of Jacobson of other 
mammals, K'olliker's interpretation having been generally accepted by 



ANATOMY. 207 

anatomists. C. Gegenbaur points out [Morphologischcs Jahrbuch, January, 
1886), however, two objections to this view, viz., the situation of the opening 
above the floor of the nasal cavity, and the relation of the tube to the carti- 
lage of Jacobson. Gegenbaur believes that this structure is a vestige of a 
considerable gland of the nasal septum which he has discovered in lemurs 
(Stenops). The objection that the mode of development of this tube is dif- 
ferent from that of glands generally is met by Kangro's observation that the 
large gland of the outer wall of the nose of mammals (Stenson's gland) 
makes its first appearance as a tubular hollow. In Gegenbaur's opinion, a 
representative of Jacobson's organ has not yet been demonstrated in man. 

On the Relation between the Calibre of the Bronchi and the 
Volume of the Lungs. 

W. Braune and H. Stahel describe (Archivf. Anatomie, February, 1886) 
an extensive series of observations upon the calibre of the large air-tubes, con- 
sidered especially in relation to the capacity of the lungs. The trachea and 
bronchi were removed from the body, and either hardened in chromic acid or 
frozen. Transverse sections were then made at certain definite spots, and 
the area of these carefully measured. That the results are trustworthy is 
shown by the close agreement that was found to exist between the area of 
the right and left bronchi and the weights of the corresponding lungs. In 
five cases the average weight of the right lung to that of the left was in the 
proportion of 100:74.9, the section of the right bronchus to that of the left 
as 100 : 75.5. The greatest individual deviation from the average proportion 
was left lung 74.8, and left bronchus 78. The following is a summary of 
the results obtained : 

The trachea is smallest immediately below the larynx ; its calibre increases 
gradually to about the middle of its length, and then diminishes to about 
three centimetres above the bifurcation, from which spot it again enlarges 
to its end. The continuous enlargement from above down, observed by 
Aeby, is explained as being due to the pressure of the column of fusible 
metal, with which the air-tubes were filled by him before being measured, 
distending unduly the lower part of the trachea. 

The sum of the sections of the two bronchi at their beginning is greater 
than the sections of the trachea 3 cm. above the bifurcation, the average 
proportion being 107.9 : 100 ; the extremes 122.8 and 85.7 : 100. In only two 
cases out of ten were the bronchi together smaller than the trachea. 

The calibre of the right bronchus at its origin to that of the left is on the 
average as 100 : 77.9, the extremes in eleven cases being 100 : 71.6 and 
100 : 83.3. The calibre of the left bronchus usually diminishes from its origin 
to its termination. The right bronchus is too short to allow of observations 
being made upon it. 

The section of each bronchus at its origin is normally greater than the sum 
of the sections of its primary branches. One exception to this rule was found 
in six cases. The same relations were found to exist between the trachea and 
the right and left bronchi in the dog, cat, and sheep. 

There is a constant relation between the weight of the lung and the calibre 
of its bronchus. In dogs the relative capacity and weight of the right and 



208 PKOG-KESS OF MEDICAL SCIENCE. 

left lungs were found to correspond closely, whence it is inferred that the 
calibre of the bronchi is directly proportionate to the capacity of the lungs. 

A definite relation between the calibre of the bronchi and the capacity of 
the lungs is also shown in pathological conditions. An emphysematous lung 
or lobe of a lung has an enlarged bronchus or primary bronchial branch, while 
affections causing a reduction in the respiratory capacity of the lung are 
accompanied by a diminution of the corresponding bronchus. The calibre of 
a bronchus depends upon the volume of air that traverses it. If the volume 
of air increases, the calibre of the bronchus also becomes increased, and vice 



On Some Points in the Anatomy of the Thyroid Gland. 

A. Streckeisen deals in a long article in the January and February num- 
bers of Virchow's Archiv with the pyramidal process of the thyroid gland, the 
muscles of the gland, the thyroid arteries, and accessory glands and cysts in 
the hyoid region. His observations were made in the Pathological Institute 
at Basle, in a district where goitre is endemic and very common. 

A pyramidal process is present, including cases of occurrence of a superior 
accessory gland which evidently arises from the separation of this process 
either before or after birth, in 79 per cent, of 153 subjects examined. It 
springs, in the great majority of instances, from one of the lateral lobes, from 
right and left with equal frequency, and comparatively seldom from the 
isthmus. The process is nearly always connected to the hyoid bone, either 
by continuous gland substance or by dense connective tissue, or by a special 
muscle. A superior accessory gland occurs in 16.3 per cent. That most of 
such glands result from the detachment of a pyramidal process is shown by 
their greater relative frequency in old than in young persons, and by the in- 
terval between the accessory and the main gland often coinciding with the 
edge of one of the laryngeal cartilages, which would appear to have been 
concerned in producing the separation. 

A musculus glandulse thyroidae occurs in nearly forty per cent, of subjects. 
It may be connected either with a pyramidal process or with the body of the 
gland. In the former case the muscle may be a hyo-pyramidalis, the more 
frequent form, derived from the thyro-hyoid or occasionally from the sterno- 
hyoid, or a thyro-pyramidalis derived from the sterno-thyroid ; in rare cases a 
muscular bundle runs transversely from the lower edge of the thyroid cartilage 
to the pyramidal process. To the body of the gland fasciculi may proceed 
from the thyro-hyoid (hyo-glandularis lateralis — the commonest of these acces- 
sory muscles), from the crico-thyroid, or from the inferior constrictor of the 
pharynx. 

The superior thyroid artery meets the gland at the apex of the lateral lobe, 
where it usually divides into two branches. The posterior branch supplies 
the upper and outer part of the lobe ; the anterior branch (ramus thyroideus) 
descends along the concave upper margin of the gland to the isthmus. It 
commonly happens that the anterior branch of one side crosses the middle 
line at the upper edge of the isthmus, simulating an anastomotic loop. In 
many cases a considerable branch [ramus thyroideus anterior) descends over 
the crico-thyroid membrane and the front of the cricoid cartilage to the 
isthmus of the gland ; such a vessel, crossing the middle of the cricoid carti- 



ANATOMY. 209 

lage, was found fourteen times in forty subjects. Anastomoses between the 
right and left arteries are scanty. 

The trunk of the inferior thyroid artery sinks behind the lower part of the 
lateral lobe of the gland, and divides into upper and lower primary branches. 
The lower branch is distributed to the inferior part of the gland ; the upper 
division ends in two branches, one of which {ramus marginalia) ascends along 
the hinder margin of the lobe nearly to its apex, while the other {ramus 
perforans) passes forward through the suspensory ligament close below the 
cricoid cartilage to the upper border of the isthmus. The last branch is 
sometimes of large size, and may extend over to the opposite lateral lobe. 

An arteria thyroidea ima was found 12 times in 120 subjects. Its origin 
was from the innominate in 6 cases, from the right common carotid in 2, and 
from the right subclavian in 4. 

Accessory glands in the neighborhood of the hyoid bone are of very fre- 
quent occurrence, and are classified by the author in the following four groups 
according to their situation: 1. Prehyoid glands, superficial to the mylo-hyoid 
muscle ; 2. Suprahyoid glands, between or in the substance of the genio-hyoid 
muscles ; 3. Epihyoid glands, above the genio-hyoid muscles ; and, 4. Infra- 
hyoid glands, lodged in hollows of the hyoid bone. Together with the glands, 
small cysts lined with ciliated epithelium are often met with in the same 
positions, and also at the apex of the pyramidal process. In one case a duct 
was found leading from the foramen caecum of the tongue to an epihyoid 
gland. All these structures, as well as the pyramidal process and the superior 
accessory gland before referred to, have a common origin, being remains of 
the neck of the central diverticulum which is protruded from the ventral wall 
of the pharynx in the embryo, and from which the middle part of the thyroid 
gland is formed. The author concludes from his researches that the foramen 
caecum indicates the spot where this diverticulum leaves the pharynx ; and 
since his paper was completed, the third part of His's Anatomie menschlicher 
Embryonen has appeared, in which this relation between the foramen caecum 
and the thyroid body is traced developmentally. He differs from His, how- 
ever, in making the thyroid diverticulum descend on the ventral aspect of the 
hyoid bone, and considers it probable that the development of the latter is 
concerned in bringing about the separation of the thyroid body from the 
pharynx. Accessory glands near the great cornu of the hyoid bone are much 
rarer than the mesial ones ; they are derived in a similar way from the lateral 
diverticula which form the lobes of the main gland. 



On the Constitution of the Lateral Column of the Spinal Cord, 
and on the origin of the ascending koot of the flfth nerve. 

Prof. W. Bechterew, of Kasan, distinguishes a region of the lateral 
column of the spinal cord, placed immediately in front of the posterior nerve- 
roots, between these and the crossed pyramidal tract. The fibres of this part 
differ from those of the neighboring territories by their small size ; and they 
begin to acquire their medullary sheath in foetuses about thirty-three centi- 
metres in length, at a time when the posterior columns are completely medul- 
lated, while the pyramidal tracts still consist altogether of pale fibres. The 
name posterior root-area of the lateral column is given to this region, since it is 

NO. CLXXXIII. — JULY, 1886. 14 



210 PKOGKESS OF MEDICAL SCIENCE. 

composed of the small fibres of the posterior roots, which ascend for a short 
distance at the outer part of the substantia gelatinosa, and then turn inward to 
the posterior horn, the author's observations on the foetal cord confirming the 
description given by Lessauer, who found this area degenerated in tabes dorsalis. 
The fibres of the ascending root of the fifth nerve are medullated in foetuses 
from twenty-five to twenty-eight centimetres long. They can then be seen 
arising in the lower part of the medulla oblongata from the cells of the base 
of the posterior horn, being placed internal and anterior to the gelatinous 
substance of Rolando. They pass outward through the latter about the level 
of the upper decussation to gain its outer surface, along which they ascend. 
They have no origin from the substantia gelatinosa. — Archiv fur Anatomie, 
February, 1886. 



PHYSIOLOGY, 



UNDER THE CHARGE OF 

GERALD F. YEO, M.D., 

PROFESSOR OF PHYSIOLOGY AT KING'S COLLEGE, LONDON. 



Function of the Posterior Cerebral Commissure. 

Working under Goltz's direction, Darkschewitsch, of Moscow, performed 
a series of experiments on the effects produced by cutting through the pos- 
terior commissure of the rabbit's brain, and has arrived at the following gen- 
eral conclusions. A lesion of the posterior commissure is always followed by 
a lessening of the excitability of both of the third cranial nerves — oculomo- 
tor ii. The degree of depression in excitability bears a relation to the amount 
of the lesion of the fibres of the commissure. Complete destruction of the 
commissure is followed by loss of function of the oculomotor ii, which is as 
complete as if the nerves were cut. The incomplete unilateral lesion of the 
fibres of the posterior commissure induces an irregular or one-sided lowering 
of the excitability of the two oculomotorii ; the oculomotorius of the side at 
which the lesion is greater is less excitable than that of the other side. — 
Archiv f d. gesammte Physiologie, etc., Bd. xxxviii. p. 120, January 26, 1886. 

Irritability of the Spinal Cord. 

M. Schiff having discussed the recent work of Mendelssohn, Gad, Bieder- 
mann, etc, on the above subject — in which some evidence had been brought 
forward tending to prove that the stimulation of the anterior columns of the 
cord was responded to by movements — gives the details of a series of experi- 
ments, mostly performed in conjunction with Prof. Reichert, of Philadelphia, 
upon the spinal cords of rabbits. He explains the apparently direct motor 
response after stimulation of the anterior columns of the frog in the same 
way as the recurrent sensibility of the anterior roots of the spinal nerves was 
accounted for by Bernard ; i. e., by supposing that there exist in these col- 



PHYSIOLOGY. 211 

umns some sensory fibres the stimulation of which elicits reflex movements ; 
and he thinks that the motor conducting elements are not capable of direct 
excitation, as is probable from the analogy to be drawn from the warm-blooded 
animals. He concludes that the conductors of motor impulses in the cord of 
mammals do not respond to stimulation, or are kinosodic. In spite of the com- 
plete confirmation given to Biedermann's results as to the anterior columns 
of the frog's cord, there is no reason to conclude that they differ from those 
of the mammal by possessing motor excitability. They do, however, possess 
a sensory excitability. — Archivf. d. gesammte Physiologie, Bd. xxxviii. p. 182, 
January 26, 1886. 

Visceral and Vasomotor Nerves. 

A remarkable paper by Dr. W. H. Gaskell on the structure, distribution, 
and function of the nerves which innervate the visceral and vascular systems 
occupies the first part of the seventh volume of the Journal of Physiology, 
and appears as the first of a series promised by the author on the above sub- 
ject. The investigation was chiefly carried out on the dog, to which animal 
the author at present restricts his conclusions. 

In the present paper he confines himself to the efferent nerves, which he 
divides into — 1. Nerves of the vascular muscles : (a) vasomotor — i. e., vaso- 
constrictors, accelerators, and augmentors of the heart; (b) vasoinhibitory — 
i. e., vasodilators and inhibitors of the heart. 2. Nerves of visceral muscles : 
(a) visceromotor; (b) visceroinhibitory. 

Those nerves issuing from the central nervous system by the branches 
known anatomically as visceral, pass by routes — which differ in the thoracic, 
lumbar, and cervical regions — to the ganglia of the visceral system, which are 
divided into three sets, viz. : 1. Lateral vertebral (sympathetic ganglia). 2. 
Prevertebral or collateral (semilunar, mesenteric, etc., ganglia.) 3. Termi- 
nal ganglia in the organs themselves, besides the ganglia on the roots of the 
spinal nerves with which also the visceral nerves may have connections. In 
the sacral region the nerves pass out from the second and third sacral roots in 
a single stream to the ganglia of the collateral chain. From the thoracic re- 
gion, from between the second thoracic and second lumbar nerves inclusive, 
they pass out in a double stream, one to the ganglia of the lateral chain, the 
other to the ganglia of the collateral chain. From the upper cervical region 
they pass out in a single stream to the ganglia on the main stems of the 
vagus and glossopharyngeal nerves, along the roots of these nerves and that 
of the spinal accessory. The gray fibres lying in the rami communicantes are- 
merely peripheral nerves passing from the lateral ganglia to be distributed to 
the vertebral tissues ; the white fibres alone then really constitute the visceral 
branch of the spinal nerve, and the outflow of visceral nerves from the cen- 
tral nervous system into the so-called sympathetic system takes place by their 
means alone. The absence of the white fibres in the communicating branches 
in the other parts of the cervical and lumbar regions indicates the localization of 
the outflow to the regions named. The white visceral branches are made up 
of peculiarly small medullated fibres which are taken as being characteristic 
of these special nerves. 

With regard to the vasomotor nerves, it is decided that the vasoconstrictor 
nerves for all parts of the body can be traced as bundles of the finest medul- 



212 PROGRESS OF MEDICAL SCIENCE. 

lated fibres (varying in size from 1.8 // to 3.6 //) in the anterior roots of all the 
spinal nerves between the second thoracic and second lumbar inclusive, along 
the corresponding visceral branch to the lateral chain (main sympathetic 
chain), where they become non-medullated, and are thence distributed to their 
destination either directly or after communication with other ganglia. Since 
in mammals all the vasoconstrictor nerves of the body leave the central ner- 
vous system in the outflowing stream in the thoracic region, and all pass in 
that branch of the stream which is in connection wiih the lateral ganglia 
when they lose their medulla, this chain might be more appropriately called 
" the chain of vasomotor ganglia." 

The point of the outflow of the visceromotor nerves is widely separated 
from the thoracic region. The nerves upon which the peristaltic contraction of 
the thoracic portion of the oesophagus, stomach, and intestines depends, leave 
the central nervous system in the outflow of fine medullated visceral nerves 
which occurs in the upper part of the cervical region, and pass by the way of 
the visceral branches of the accessory and vagus nerves to the ganglion 
trunci vagi, where they become non-medullated. They therefore resemble in 
their structure, and in the method of their distribution, the vasomotor nerves 
already described. A corresponding set of visceromotor nerves for the 
organs in the pelvis springs from the sacral outflow. The vasoinhibitory 
nerves seem to conform to the type of the cardioinhibitory nerves, with 
which they may be classed. Certainly those vasoinhibitory nerves of which 
we know most (in chorda tympani and nervi erigentes) seem to leave the 
central nervous system among the fine medullated nerves which help to form 
the cervico-cranial and sacral rami viscerales, and pass, without altering 
their character, into the distal or terminal ganglia. Little being known 
about viscero inhibitory nerves, it can only be concluded in reference to them 
that the inhibitory nerves of the circular muscles of the alimentary canal 
and its appendages leave the central nervous system in the anterior roots, and 
pass out among the fine medullated fibres of the rami viscerales into the 
distal or terminal ganglia without communication with the proximal (lateral) 
ganglia. The nerves which supply the muscles of the vascular and visceral 
systems have then certain common histological characteristics, being all com- 
posed of medullated fibres of the finest size ; and further, the nerves of the 
same function possess in addition a well-defined anatomical course. The 
ganglia, besides presiding over the nutrition of the nerves passing from 
them to the periphery, have the function of converting the medullated into 
non-medullated fibres and increasing the number of nerve fibres simul- 
taneously with the loss of the medulla. It may be said, then, that each 
visceral fibre leaves the central nervous system as a fine medullated nerve 
fibre, which passes directly to its appropriate ganglion, and there, in conse- 
quence of communication with one or more of the ganglion cells, loses its 
medulla and passes out, not as a single non-medullated fibre, but as a group 
of non-medullated fibres. 

In considering the nature of the action of the motor and inhibitory nerves 
of the vascular and visceral systems, the chief stress is laid on the cardiac 
innervation. Here two nerves, antagonistic in their action, are known. The 
sympathetic, which may be termed motor, because it augments the activity 
of the cardiac muscle, and this augmentation is followed by exhaustion ; and 



PHYSIOLOGY. 213 

the vagus, which is the inhibitory nerve capable of lowering the excitability 
and conductivity of the cardiac muscle, diminishing the contractions and 
slowing the rhythm. This moderation of activity is productive of a bene- 
ficial effect on the tissue ; the result of stimulating these nerves, then, ex- 
actly opposite. In the one case (sympathetic) there is increased activity 
followed by exhaustion, symptoms of katabolic action ; in the other (vagus), 
diminished activity followed by repair of functions, symptoms of anabolic 
action. It is supposed to be probable that every tissue is thus supplied with 
exciting (katabolic) and calming (anabolic) nerves, by the mutual action of 
which their functional activity, and consequently their chemical interchanges 
and nutrition, is regulated. With regard to the central origin of the visceral 
branches of the spinal nerves, attention is called to the fact that Clarke's 
vesicular column of the spinal cord may be regarded as a discontinuous 
column, the cell-groups of which it is composed being limited to definite and 
separate regions, viz., cervico-cranial, thoracic, and sacral. This vesicular 
column is most conspicuous in the thoracic region, commencing about the 
origin of the second thoracic nerve, and continuing along the whole thoracic 
part of the cord to about the origin of the second lumbar nerves ; it corresponds 
absolutely to the region of the thoracic outflow of visceral nerves. Below the 
level of the second lumbar, in the sacral region, there is a localized nucleus 
of cells belonging to this cell-column, known as " Stilling's sacral nucleus." 
This corresponds to the outflow of the sacral visceral nerves. On the level 
of the second cervical nerve, this column of cells again makes its appear- 
ance, forming the so-called cervical nucleus, the continuation of which leads 
into the nuclei of the vagus, and glossopharyngeal nerves. From this it is 
considered conclusively proved that the cells of Clarke's column are con- 
fined to those regions of the central nervous system which give rise to the 
nervi viscerales. 

Considering the nerve-roots which arise from the upper cervical segments 
as typical, all spinal nerves may be said to be formed of three roots, viz. : 
(1) An anterior non-ganglionated root in connection with the cells of the 
anterior horn. (2) A posterior ganglionated root in connection with the 
cells of the posterior horn. (3) A lateral root, again divisible into (a) a 
ganglionated root in connection with Clarke's column ; (b) a non-gangli- 
onated root in connection with the cells of the lateral column. In accord- 
ance with the distribution of the fibres contained in these roots, the origin of 
the nerve of each spinal segment may be described as follows : (1) A somatic 
root composed of two portions, a ganglionated and non-ganglionated, arising 
from two columns of nerve cells, viz., the columns of the posterior and 
anterior horns respectively. (2) A splanchnic root composed also of two 
portions, a ganglionated and a non-ganglionated, arising also from two columns 
of nerve-cells, viz., the column of Clarke and that of the lateral column. 
The resemblance in the structure of these nerves points to the conclusion 
that the ganglia of the sympathetic system are homologous to the ganglion 
trunci vagi, and form the ganglionated portion of the splanchnic roots. 

The relationship of the cranial nerves is worked out on the same system, 
for which reference must be made to the original. — Journal of Physiology, 
January, 1886, vol. vii. No. 1. 



214 PKOGRESS OF MEDICAL SCIENCE. 

Development of the Sympathetic Nerve. 
Onodi, in a third paper on the above subject, gives many details of the 
earlier steps in the growth of the sympathetic ganglia, etc., from which the 
following may be concluded : The intervertebral ganglia are immediate 
products of the process of cell-proliferation occurring in the medullary tube. 
Both the anterior and posterior roots appear as fine fibres growing out of the 
medullary tube, the anterior being the first to appear. The sympathetic 
ganglia are the direct products of the process of cell-proliferation which 
takes place on the ventral aspect of the intervertebral ganglia. They are 
made separate ganglia by subsequent constrictions. The sympathetic cord is 
a secondary product, the result of an outgrowth from the adjacent ganglia. 
The visceral networks and ganglia are direct products of the sympathetic 
cord. Each sympathetic ganglion is connected with the intervertebral gan- 
glion, the anterior root, and the anterior and posterior branches of the spinal 
nerves. The fibres from the spinal cord pass with a definite system to the 
sympathetic ; in the upper thoracic region most of the bundles pass upward, 
in the lower part of the spinal cord the greater number of bundles pass in a 
downward direction. The terminal ganglionic cells in the organs probably 
have a separate origin. — Arch.f. Microskop. Anatomi, March 5, 1886. 



MATERIA MEDIGA, THERAPEUTICS, AND 
PHARMACOLOGY. 



UNDER THE CHARGE OF 

ROBERTS BARTHOLOW, M.D., LL.D., 

PROFESSOR OF MATERIA MEDICA, GENERAL THERAPEUTICS, AND HYGIENE IN JEFFERSON MEDICAL COLLEGE, 

PHILADELPHIA. 

The Bark of Quebracho Blanco and its Active Principles. 

Under this caption, MM. Charles Eloy and Henri Huchard publish, 
in the Archives de Physiologie, Normale et Pathologiques, etc., for April, 1886, 
an exhaustive paper. We lay before our readers some of the more important 
of their observations : 

The active principles of quebracho are aspidospermine, quebrachine, aspi- 
dospermatine, hypoquebrachine, aspidosamine, and quebrachamine. 

The physiological action and poisonous properties of the pure aspidosper- 
mine are shown in the following phenomena produced in the rabbit and the 
dog, by a two per cent, solution : 

a. Action on voluntary movements. After doses of eight to fifteen centigrammes, 
successively administered, aspidospermine produces convulsions which first 
appear in the posterior members, and afterward become general ; then mus- 
cular tremblings, and, when elimination does not take place, paralysis. 

b. Action on sensibility. In no case has the peripheric sensibility been 
weakened. However, in the rabbit, they have ascertained the augmentation 
of the electrical excitability of the phrenic nerve. 



MATERIA MEDICA AND THERAPEUTICS. 215 

c. Action on the circulation. Under its influence, the frequency of the cardiac 
pulsations became less ; from 156 their number is diminished to 126. At the 
same time there were noticed an intensely red coloration and turgescence of 
the vessels of the pavilion of the rabbit's ear. 

d. Action on respiration. Aspidospermine modifies the respiratory move- 
ments, first and temporarily in amplitude, later and permanently in frequency. 

e. Action on temperature. The lowering of the rectal temperature is constant 
under the influence of this agent, aud appears in relation at the same time 
with the activity of the elimination and with the dose administered. To judge 
of the antithermic value of aspidospermine, it is therefore necessary to take 
notice at the same time of the dose employed and of the activity of the 
elimination. 

Physiological action and poisonous properties of the lactate of quebrachine. The 
investigations were made with a one per cent, solution on guinea-pigs and 
rabbits. The following are the conclusions : 

a. Action on motility. Five or ten minutes after the subcutaneous injection, 
violent convulsions are observed ; soon they give place to a paralysis of the 
posterior members, becoming general afterward. Besides, an almost constant 
phenomenon observed is the change in the guinea-pig's voice, which becomes 
hoarse, and later is lost. 

b. The reflex excitability so increases that moderate excitations provoke distant 
violent muscular contractions. The sensibility does not seem to lessen. 

c. The modifications of temperature are considerable. Five minutes after the 
first injection, the temperature of the guinea-pig diminishes, and when the 
doses are small the thermometer is lowered from five to seven degrees in the 
space of ninety to one hundred minutes. An increase in quantity of urine 
was observed. After large and manifestly poisonous doses, asphyxia and 
death occurred rapidly. 

d. Respiration does not undergo modifications comparable to those induced 
by aspidospermine. After physiological doses, the rabbit preserved the 
rhythm and amplitude of the respiratory movements. 

e. Action on the blood. ' The color of the blood is more variable ; and, in 
grouping the observations, it was noticed that it is black when the animals 
succumb to asphyxia by paralysis of the respiratory muscles, and red when 
the thermogenic depression is more considerable. 

/. The secretions increased every time when the experiment was sufiiciently 
prolonged. Increase of the diuresis of rabbits and guinea-pigs and the 
humidity of the buccal cavity bear witness to the elimination of quebrachine 
by the buccal glands and by the kidneys. It is in direct relation to the 
lowering of the rectal temperature. 

In equal weights and in the same experimental conditions, quebrachine is 
more active and more poisonous than aspidospermine ; it possesses a greater 
antipyretic action, but does not modify the rhythm of the respiratory move- 
ments. 

The physiological action and toxic qualities of aspidospermatine. The watery 
solution of lactate of aspidospermatine was used upon guinea-pigs and rabbits. 

a. Under its influence the motility weakens ; and if the dose is toxic, con- 
vulsions are produced. If the dose is less considerable, there is a muscular 
paresis of the extremities. 



216 PROGRESS OF MEDICAL SCIENCE. 

b. The sensibility is preserved. 

c. The circulation is modified, and in the guinea-pig they have noticed 
acceleration of the cardiac pulsations. 

d. The respiration preserves its rhythm in guinea-pigs. In an experiment 
upon a rabbit, we have remarked a decrease in the amplitude of the respira- 
tory movements, compensated for by an increase of their frequency. 

e. The temperature is lowered when the aspidospermatine is administered 
in successive doses. This lowering varies from three to six degrees in a space 
of time from nineteen to twenty minutes, so that in the relation of time and 
doses it is represented by the numbers 1, 1.5, 2.5. The aspidospermatine 
must then be regarded as a powerful antipyretic. 

/. Its action upon the blood is interpreted by the changes of coloring like 
those which the aspidospermine produces. The blood of the veins becomes 
red, but only in cases of a gradual decline in temperature. 

g. The intestinal and urinary secretions increase, and thus the slowness 
with which the toxic phenomena are developed is explained. The intestines 
and the kidneys then increase the elimination of this substance. 

h. The first appearance of all these phenomena is observed in from three to 
five minutes after the subcutaneous injection ; it is slower, and is only mani- 
fested between the sixteenth and twentieth minute, when diarrhoea and an 
intestinal hypersecretion exist. 

By its antipyretic properties, aspidospermatine equals and even surpasses 
the other immediate principles of the bark of quebracho. 

Physiological action and toxic properties of sulphate of hypoquebrachine on 
motility. A large dose (two per cent, solution) lessens motility, but in some- 
what smaller closes induces tonic and clonic convulsions. It does not affect 
sensibility, nor has it any influence over the circulation ; but it lowers the 
temperature considerably. The blood, when large doses have been given, 
assumes a vermilion hue ; and is black when death has been caused by large 
doses that paralyze respiration. It is absorbed more rapidly than is aspi- 
dospermine and quebrachine, and the action begins in four or five minutes 
after its hypodermatic administration. 

The following are the general conclusions arrived at by the authors : 

1. The active principles of quebracho modify little the general sensibility of 
mammals (guinea-pig, rabbit, dog). Quebrachine, hypoquebrachine, aspi- 
dospermine, and aspidospermatine, in their pure form, do not weaken this 
function; but the residual products of their extraction appear to diminish it. 

2. In some experiments, after the administration of aspidospermine and 
of quebrachine, the increase of the galvanic excitability of the phrenic nerve 
is proved. 

3. Motility is variously affected. In large doses, aspidospermine provokes 
convulsions ; in feeble doses, tremors ; in massive doses, a rapid paralysis. 
A remarkable phenomenon is the hoarseness and loss of voice of the animals 
under observation, especially guinea-pigs. This phenomenon must be at- 
tributed to the paralysis of the tensor muscles of the vocal cords. 

Quebrachine produces muscular paralysis more rapidly and more mani- 
festly. Hypoquebrachine and aspidospermatine have a similar action, but 
less distinct than that of aspidospermine. 

The residual products provoke a complete and rapid paralysis. Beginning 



MATERIA MEDICA AND THERAPEUTICS. 217 

at the extremities of the limbs, four or five minutes after the subcutaneous 
injection, this paralysis extends rapidly to the whole body, and alternates 
with tonic convulsions. 

4. The circulation is not modified by the residual products nor by hypo- 
quebrachine or quebrachine. By way of compensation, they have remarked 
retardation of the cardiac pulsations under the influence of the aspidosperma- 
tine injections. 

5. It was of practical interest to review the work of preceding investigators 
from the point of view of the action of the principles of quebracho upon the 
respiration, since this bark has been extolled as a remedy for dyspncea of 
various kinds. 

Quebrachine changes neither the rhythm nor the extent of the respiratory 
movements. It is the same with the residual products and with aspidosper- 
matine. The hypoquebrachine modifies them feebly. This role belongs 
especially to aspidospermine ; it increases at first the extent of the respiratory 
movements in the proportion of 1 to 5 in eight or fifteen minutes ; then, a 
moment after, it changes the rhythm in increasing their frequency in the 
relation of 11 to 12 (rabbit), or of 10 to 11 (dog). This increase persists 
during two, three, or even four hours. 

This is not all; by increasing the dose, or in the absence of elimination, a 
disorder of the rhythm and a diminution in the extent of the respiratory 
movements are induced. Besides, in pursuing the experimental analysis of 
these phenomena, they have ascertained, first, that these modifications affected 
in the same way the respiratory movements of the thorax and those of the 
abdomen, for the parallel graphic traces of these two orders of movements 
show that the enlargement of the movements of the thoracic wall is already 
apparent at the beginning — that is to say, at the moment where the respiratory 
abdominal movements are not yet modified ; secondly, that the number of 
costal respirations grow as 2 to 1 ; those of the ventral respirations increase 
as 1 to 1. 

6. Consequently the aspidospermine modifies more energetically the fre- 
quency of the costal respiration than the frequency of the abdominal respira- 
tion. It is, then, right to consider it as the modifying agent of the respiratory 
movements, the most active among all the principles of quebracho. 

7. All the active principles of quebracho have the power to modify the 
temperature. The residual products raise it; but this elevation seems to 
reenter in the category of the phenomenon of asphyxia. The aspidospermine 
of commerce lowers it from two to three degrees in the space of thirty to forty 
minutes; the pure aspidospermine following the numerical progression of 
|, 1, H, etc., has relation rather with the rapidity of the elimination than 
with the size of the dose. The aspidospermatine makes the thermometric 
column descend three or six degrees in nineteen minutes, following the pro- 
gression of 1, 1 J, 2, or 2J. It is the same with the hypoquebrachine. 

Of all these substances the most decidedly antipyretic is the quebrachine. 
In broken doses it lowers the temperature five to seven degrees in ten minutes. 
With the aspidospermatine, then, it possesses an antipyretic power superior 
to that of all the other active principles of quebracho. 

8. The coloring of the venous blood merits attention. Black, when the 
animal suffocates under the influence of residual products ; it is rose color or 



218 PROGRESS OF MEDICAL SCIENCE. 

currant-red by the action of quebrachine, of hypoquebrachine, of aspidosper- 
matine, and of aspidospermine — that is to say, of the principles which lower 
the temperature. What is the nature of this blood modification ? The spec- 
troscopic and hematologic researches that we have made with the valuable 
aid of M. Henocque, and by his ingenious method have proved there is a 
quantitative diminution and not a qualitative change in the haemoglobin. 
Further, the histologic examination of the blood globules has demonstrated 
their integrity ; they preserve both their form and reactions at different periods 
in the course of these observations. 

9. These principles increase the secretion of the kidneys, intestinal and 
salivary glands. Hypoquebrachine and aspidospermine cause diarrhoea, and 
act as diuretics; quebrachine increases diuresis; aspidospermine the salivary 
secretion of the dog, the urine of the guinea-pig and of the rabbit. The 
residual products have the same action upon the secretory activity of the 
intestine and of the kidneys. It is manifest that these are methods of elimi- 
nation, as has been accounted for in examining comparatively the changes of 
the temperature, the respiratory troubles, and the variation of the blood 
color. 

10. Finally, in relation to their toxic power, all these constituents of que- 
bracho can cause death. The most toxic are the residual products; next 
come quebrachine, hypoquebrachine, aspidospermatine, and in the last rank 
aspidospermine. Death occurs, either in asphyxia, by paralysis of the muscles 
of respiration when the doses are large, or more slowly, by the arrest of the 
exchanges, when the doses are physiological and the elimination partial. 
Therefore by the graduated use of these principles, always with the exception 
of the residual products, useful effects can be obtained in therapeutics. 

It is sufficient to say that the bark of quebracho is not a substance medi- 
cinally inert, and that, if it does not always respond to the excessive enthu- 
siasm of its first patrons, it merits something more than disdain or indifference. 

In the observations on temperature made by the authors of this paper, we 
find no allusion to the remarkable decline in the body heat of rabbits, which 
occurs when they are kept immobile. This circumstance must vitiate any 
conclusions reached by the experimenters, when so important a fact is over- 
looked. That this normal decline of temperature affected the results in this 
investigation is evident from some of the experiments, in which the decline 
took place without any apparent explanation of the occurrence. 



Calomel in the Treatment of Hypertrophic Cirrhosis and other 

Affections. 

As an indication of that revival which is evidently taking place in the use 
of mercury, according to the old antiphlogistic conception, we place before 
our readers some of the principal points in a paper by Sacharjin ( Centralblatt 
j'ur die gesammte Therapie, January, 1886) under the above caption. 

In diseases of the biliary ducts, Sacharjin holds that we have in calomel the 
most valuable remedy which the present state of therapeutics affords. The 
special conditions in which it is most effective, are that catarrhal thickening 
which succeeds to the inflammation produced by the passage of gall-stones, 
and in hypertrophic cirrhosis. The cases of the former are those in which, 



MATEEIA MEDICA AND THERAPEUTICS. 219 

after repeated attacks, in quick succession, of biliary colic, there is constant 
pain in the region of the gall-bladder, and much uneasiness is felt throughout 
the whole hepatic area, there being at the same time more or less feverishness. 
His practice consists in the administration, every hour or two, of grain doses 
until twelve grains are taken, after which should no cathartic action occur a 
dose of castor oil is given. During the administration of the calomel, and 
for a few days thereafter, the mouth is rinsed out with chlorate of potash solu- 
tion, to avoid ptyalism. 

Sacharjin, like many others, has seen the advantage of calomel in the treat- 
ment of typhoid. He gives it in the first week, not later than the eighth or 
the ninth day of the attack, and indeed at any time, should there be no diar- 
rhoea. Calomel exhibited to induce a purgative effect, lowers the temperature 
for one or two days, and gives the patient a relatively quiet night or two. 
His rule consists in giving the calomel in grain doses hourly until twelve 
grains have been taken, after which, should it not purge, he prescribes castor 
oil. He rejects the theory of its action on the microbes of typhoid. 

Sacharjin, during his first two years of practice, in treating croupous pneu- 
monia, relied on digitalis, but finally became convinced of its inutility. He 
was equally disappointed in cold baths. Quinine to be effective in reducing 
the temperature must be administered in massive doses, and such quantity 
has a bad effect on the stomach and disorders the nervous system. The 
remedy which he has finally decided on is calomel, which he gives, as men- 
tioned under the head of typhoid, except that in sthenic cases he begins its 
use with the onset of the disease. Very often he finds that the fall of tempera- 
ture induced by the calomel determines the occurrence of the crisis. 

Sacharjin finds that in acute Bright' s disease, which develops idiopathically, 
without being induced by a previous infectious malady, even in those cases 
which occur in the puerperal state but are not due to puerperal infectious 
diseases, calomel given as already described has an excellent effect ; a signifi- 
cant fall of temperature takes place, the renal pains subside and the urine 
increases in amount and improves in quality. If the temperature rises again, 
and the patient's strength permits, the calomel is given again. 

In the various acute maladies for which Sacharjin prescribes calomel, the 
contraindications to its use are, besides the weakness of the patient, princi- 
pally feebleness of the pulse and diarrhoea, especially if the stools are profuse 
and exhausting. 

Urethan: its Physiological Actions, and Antagonism to 
Strychnine. 

In an elaborate paper, which appeared in the Bulletin General de Thera- 
peutique, for April 30, 1886, Prof. Coze, of Nancy, examines the action of the 
new hypnotic urethan. We give his conclusions : 

Urethan is a carbamate of ethyl. Its solubility in water renders its ad- 
ministration easy. It has a decided hypnotic action, and in large doses 
determines complete muscular resolution and anaesthesia. It slows the pulse 
and lowers the temperature. It is free from local irritant action, and can be 
administered by subcutaneous injection. It does not coagulate the fluids of 
the body or derange nutrition. It is a functional antagonist of strychnine. 



220 PROGRESS OF MEDICAL SCIENCE. 

It is indicated in man in the case of convulsions in general, and especially 
in tetanus. 

The experiments to determine the antagonism of urethan to strychnine 
were made on frogs, rabbits, guinea-pigs, and dogs, and were most striking 
in their results. Control experiments were not omitted. As respects the 
animals named, the antagonism was complete ; it is not to be doubted that in 
man the same satisfactory results may be obtained. We can, therefore, unite 
with the author in urging on our surgical colleagues the use of this new 
medicament in tetanus. 

Terpene in Chronic Bronchitis. 

Dr. Rieu, in the Gaz. mid. de Strasbourg, abstract in Bull. Gen. de Therap v 
April 30, 1886, gives the following conclusions from the clinical study of 
terpene as employed in chronic bronchitis : 

Terpene is readily taken, as it is without odor or taste, and the dose, which 
is one or two grammes (fifteen to thirty grains) a day, has absolutely no 
injurious action. In bronchitis and bronchorrhcea, with abundant purulent 
expectoration, it greatly reduces the amount of matter brought up. The 
mucopurulent expectoration of phthisis is not affected by it. It is not 
superior to creasote, Venice turpentine, and other balsamic preparations of 
the same character. As it is so little offensive, we may conclude from the 
observations of Dr. Rieu that this is its chief merit compared with the other- 
members of this group. 

Action of Amyl Nitrite. 

L. Schweinburg, in the Centralblatt fur die medicdnischen Wissenschaften ,, 
1886, No. 1, p. 13, in a study of the effects of amyl nitrite, finds that there are 
differences in its action on the vessels, according to the period after adminis- 
tration and size of the dose. It is universally agreed that a fall in the blood- 
pressure is the result of the inhalation of this agent in animals. When the 
state of the vessels is examined by means of Basch's sphygmanometer, 
Schweinburg has ascertained that just at the moment the characteristic 
symptoms — flushing of the face, a sense of heat, and rapid beating of the heart 
and carotids — are produced, the blood-pressure rises. When the full effect is- 
reached, there is always a fall in the blood-pressure, whether a full dose or a 
rapid succession of small doses be given by inhalation. Small doses given 
for therapeutical purposes always cause a rapid rising of the blood-pressure — 
by which statement we suppose he means doses not sufficient to cause distinct 
physiological effects. 

Physiological and Clinical Action of Grindelia Robtjsta. 

An immense number of articles having appeared, especially in the 
American medical press, on the subject of grindelia robusta and its effects in 
curing and alleviating asthma, bronchitis, etc., Dr. Vasili Dobroklowski, 
Chief of Prof. Botkin's Clinic in St. Petersburg, who seems well acquainted 
with all that has been written about this drug, finding that previous writers 
had confined their attention chiefly to its clinical effects, determined to 
investigate its physiological action on warm and cold-blooded animals. 



MATERIA MEDICA AND THERAPEUTICS. 221 

Having carried out an elaborate series of sixty-eight experiments on frogs, 
•dogs, and rabbits, and having administered it in ten clinical cases, he has 
come to the following conclusions (Vratch, 1886, No. 2) : 

1. The chief effect of moderate doses of fluid extract of grindelia robusta 
•on the heart and circulation, is to diminish the number of cardiac contrac- 
tions and to raise the arterial pressure. 

2. The diminution of the number of cardiac contractions in warm-blooded 
animals is due to stimulation of the inhibitory nervous apparatus of the 
heart, and especially of that part of it which is situated in the medulla 
■oblongata. 

3. The elevation of the blood-pressure is caused by contraction of the 
bloodvessels, which is due partly to direct action of the extract, and partly 
to its stimulating effect on the vasomotor centres of the spinal cord, the 
medulla, and the cerebrum. 

4. It diminishes the irritability of the different vasomotor nerves of the 
heart and vessels, as also that of the motor nerves and voluntary muscles. 
It is found that the irritability of the central apparatus falls more readily — 
i. e., more quickly and with smaller doses — than the peripheral, and that the 
irritability of the nerves is more readily lowered than that of the muscles. 

5. The therapeutic effect of the fluid extract consists in diminishing and 
regulating the cardiac contractions. Its diuretic action is not of a strongly 
marked character. 

6. Its regulating action on the nerves of the heart is greater than that of 
digitalis, adonis vernalis, convallaria majalis, and even than that of chloral 
hydrate. Its dicrotic action is less than that of digitalis and adonis vernalis. 

The author considers that in many heart cases in which other remedies 
have failed, a combination of grindelia robusta with adonis vernalis holds 
out a hope of success. The dose of the fluid extract given by him was thirty 
•drops three or four times a day. 

The foregoing observations of Dr. Dobroklowski are confirmatory of a 
physiological investigation made by the reviewer several years ago (Bartholow's 
Mat. Med. and Therap., 5th ed., p. 609). He has not, however, referred in 
the paper from which the above abstract was made, to the pronounced cere- 
bral effects of grindelia, more especially its hypnotic action. How far the 
•changes in the intracranial circulation, due to the action of this agent on the 
vasomotor system, may be responsible, does not appear. 

Kesults of Administration of Thallin, and Caution as to its 
Physiological Effects. 

Dr. Karst, of St. Petersburg, has made 202 observations on the effects of 
thallin, giving it in doses varying from 1J grains to 10 grains. A reduction 
of from 0° to 4° C. occurred in 122 of these; usually the reduction was 
between 1° and 3° C, but in 14 cases it was between 3° and 4°. The in- 
terval which elapsed between the administration of the drug and the 
maximum fall of temperature varied from 1 to 4 hours, but was most com- 
monly 1 hour. The duration of the reduction was in a few cases, especially 
where large doses were given, as much as 5 or even 6 hours, but it usually 
varied from 1 to 4 hours, the most frequent time being 2 or 3 hours. 



222 PKOGRESS OF MEDICAL SCIENCE. 

The complications observed were rigors (25), perspiration (98), nausea (2) r 
and vomiting (12). The author found that a severe rigor could be arrested 
by thallin given at the time. In a very few cases there were slight reduc- 
tions in the pulse and respirations. The urine was of a dark brown color in 
cases where large quantities of thallin were taken. The urea diminished 
during the administration of the drug, and after this was discontinued 
increased to about the same amount as before, but after the lapse of a few 
days became much more abundant, from which the author concludes that the 
diminution of urea during the administration is not due, as Maragliano sug- 
gested, to decreased oxidation at that time, but to the retention in the system 
of the effete and poisonous products of the decomposition of the tissues, 
which Dr. Karst thinks should induce us to use thallin with caution. A 
similar result has, he remarks, been obtained by Dr. Jacubowitsch in the case 
of antipyrin, and he himself is now making experiments with resorcin, 
naphthalin, antipyrin, quinine, carbolic acid, trichlorophenol, salicylic acid, 
and cold baths, with the object of elucidating this question. 

We are indebted to Dr. Maxwell, of Woolwich Common, England, for 
these translations from the Russian. 



SURGERY. 



In Europe. 

under the charge of 

FREDERICK TREVES, F.R.C.S., 

SURGEON TO, AND LECTURER ON ANATOMY AT, THE LONDON HOSPITAL. 



Recent Surgical Literature. 

So many additions have been made to the literature of surgery during the 
past few months that the more notable only can be dealt with. 

Prof. Verneuil has issued the fourth volume of his "Memoires de Chi- 
rurgie" under the title of Traumatisme et Complications (Paris, 1886). The 
work forms a very bulky volume. The style is verbose and diffuse, and the 
matter ill-arranged. The book, however, contains a vast amount of valuable 
clinical material, and forms a very important contribution to modern surgery. 
The first part is occupied with an account of injuries of various kinds based 
upon a great mass of clinical data. Then follows a masterly paper by Dr. 
Manoury on traumatic fever. Next succeeds a monograph by Dr. Dunoyer 
on the influence of intercurrent maladies and conditions upon injury. This 
subject Prof. Verneuil has made peculiarly his own, and it is remarkable that 
his work has excited so little attention elsewhere. The greater part of the 
book — no less than 300 pages — is devoted to erysipelas. The clinical features 
of the disease form the main points of the discourse, and rare forms of ery- 
sipelas, such as the recurrent and the hemorrhagic, are most exhaustively 
dealt with. 



SURGERY. 223 

Verhandlungen der Deutschen Gesellschaft filr Chirurgie (Berlin, 1886). The 
last volume of the transactions of this Society will attract considerable atten- 
tion. Many of the papers have been already reviewed. The more important 
communications are the following : Prof. Volkmann's paper on the surgical 
aspect of tuberculosis — a paper already well known ; Braun on the treatment 
of intussusception ; Sonnenburg on partial resection of the bladder ; Wolff 
on the treatment of cleft-palate ; Wolff and Bessell-Hagen on the treatment 
of club-foot ; and Kraske on excision of rectal cancer. 

Prof. Heineke's work on operative surgery, Compendium der chirurgischen 
Operationen, und Verbandlehre (Erlangen, 1886), is at last completed. It forms 
a bulky volume of 920 pages, with 451 illustrations. The work is very disap- 
pointing. The ground covered is extensive, but the matter is by no means 
up to date. The operations with which the names of German surgeons are 
more particularly associated are well described, but the author appears loath 
to extend his efforts beyond the German school. Many chapters — such as 
that on plastic operations and the surgery of the stomach — are very good, but 
the account of the radical cure of hernia is practically useless and out of date. 
The same may be said of the more recent operations upon the bowel, of 
ovariotomy, and the operative precedures directed against the uterus. The 
illustrations are poor and sketchy. 

Nouveaux Elements de Chirurgie Operatoire, by Prof. Chalot (Paris, 
1886). This book, published as one of the series of manuals issued by Doin, of 
Paris, is deserving of great praise. The work is small, is profusely illustrated, 
and is sold at the low price of eight francs. So many excellent works on 
operative surgery exist in the French language that nothing but the admirable 
character of this work could excuse its existence. It is intended mainly for 
students practising operations upon the dead body. The matter is well 
arranged, and the various subjects are discussed in concise and simple lan- 
guage. The book is well up to date, the most modern procedures are included, 
and the illustrations are among the best that we have seen. No recent book 
has covered so wide a ground in so small a space. None, with which we are 
acquainted, is more comprehensive. Indeed, it is not too much to say, that it 
is the most excellent manual on operative surgery, for its size, that has been 
lately issued. 

La Therapeutique Medico-chirurgicale en 1885 (Paris, 1886). This is the 
first issue of this work. It represents the annual volume of Le Repertoire de 
Therapeutique, and professes to give an account of all that is new in the 
matter of treatment for all countries. The articles are 224 in number, are 
contributed by various authors, and the general plan of the book is similar to 
that of the English Year Book of Treatment. As may be supposed, the work 
of French surgeons and physicians preponderates. The book, however, pro- 
vides an excellent and very well-selected summary. It contains a novelty in 
the form of a section for " professional questions, medical ethics, etc.," and also 
a series of special articles by well-known authors. The chief of these that are 
of surgical interest are the following: on double hydrocele, by Prof. Trelat; 
on orchitis, by Dr. Barette ; on the surgical treatment of vesical tumors, by 



224 PROGRESS OF MEDICAL SCIENCE. 

Dr. Pousson ; on cholecystotomy, by Dr. Cyr. The work concludes with a 
most convenient collection of new formulae. The surgical element in the book 
is very well represented. 

The seventh volume of the Compendium Annuaire de Therapeutique (Paris, 
1886) has also just appeared. It professes to deal with the chief medical and 
surgical work in all countries. The compilation is, however, very imperfect, 
the matter ill-arranged, and an overwhelming position given to the considera- 
tion of new drugs. The surgical sections are very poor. 

Des Fractures Spontanees, by Paul Simon (Paris, 1886). This thesis 
gives a complete and elaborate account of spontaneous fractures. It deals 
first with spontaneous fractures due to muscular violence and with the ques- 
tion of physiological fragility in bone. The next section concerns pathologi- 
cal fractures, those due to epiphysitis and other bone diseases, to bone tumors, 
to syphilis, to osteomalacia, and some less notable conditions. The concluding 
chapter deals with dropsy of bone. There is little in the work that is original, 
but as an exhaustive and carefully prepared monograph upon these peculiar 
lesions the book will be received with pleasure. Compilations of this kind 
are of considerable value. 

Coxo-tuberculose, by Prof. Lanxelongue (Paris, 1886). All those who 
read Professor Lannelongue's work on cold and tubercular abscesses and on 
tuberculosis of bone, published some years ago, will be able to anticipate the 
character of this monograph upon hip-joint disease. 

The book is a masterpiece, and may be commended to the notice of every 
surgeon who is interested in this common malady. The pathological section 
is full of original matter, the illustrations are excellent, and the general 
treatment of the subject exhaustive. The etiology of the disease, its clinical 
aspect, the details of its prognosis, diagnosis, and treatment, are all dealt with 
in a thorough and original manner. There is little doubt that the work will 
become well known. 

La Sorofule, by Dr. Van Merris (Paris, 1886). This is a large work of 
some 650 pages. It deals almost exclusively with the subject of scrofula in 
reference to treatment by sea-bathing. It is a work of little or no value, and 
is not constructed upon scientific lines. It gives a good account of the various 
hospitals for the treatment of scrofula in England and America, and is 
crammed with statistical matter. The author proceeds to consider the treat- 
ment of every possible form of strumous disease by sea-bathing. The work 
is weak and one-sided. 

Die Hygiene und JEsthetih des Menschliehen Fusses, byLuDWio Shaffer 
(Vienna, 1886), is a somewhat remarkable book. Its subject, the hygiene and 
"aesthetics" of the human foot. It enters fully into the mechanism of the 
foot and the subject of boots, and especially of military boots. The book 
will be read with interest by orthopaedic surgeons, to whom it presents many 
valuable hints. 

Le Mai Frangais a VEpoque de V Expedition de Charles VIII. en Italie, by Dr. 
Hesxatjt (Paris, 1886). This little volume furnishes an account of syphilis 



SURGERY. 225 

("the French disease") as it appeared at the period named — i. e., about the 
end of the fifteenth century. It is a valuable contribution to the history of 
this disease and to the general history of medicine. The book is somewhat 
marred by long quotations from Latin documents. It is admirably printed 
and got up. 

The first volume of the Transactions of the Congres Francais de Chirurgie 
has appeared (Paris, 1886). It represents the work of the first session of 
this important Society, and contains many papers of considerable value. 
Amongst the chief subjects discussed are the following: Tarsectomy in talipes 
varus; the etiology and pathology of infectious surgical disorders; the state 
of the urine in surgical maladies ; cold abscess ; the treatment of ruptured 
intestine. 

Des Affections Rheumatismales du Tissu Cellulaire Sous-cutane, by Dr. Chtjf- 
fart (Paris, 1886). This monograph covers considerable ground, and con- 
cerns such diverse affections as the following : Eheumatic oedema, rheumatic 
nodes, lipoma, "secondary elephantiasis," Dupuytren's contraction, and 
scleroderma. All these affections the author regards as due to rheumatism. 
His conclusions will probably not meet with general approval, and in some 
respects may be considered to be a little extravagant. The book, however, is 
written with spirit and in an original manner, and opens up questions well 
worthy of investigation. 

Ueber den Shock, by Dr. Grceningen (Wiesbaden, 1885). This important 
treatise should have been noticed in a previous summary. It provides an 
admirable review of the whole subject of collapse. It deals with the physi- 
ology of shock, the various theories as to its production, its clinical aspects, 
diagnosis, and treatment. A work of this kind, as representing the present 
state of knowledge upon one important surgical condition, is of great value, 
and that value is enhanced by a very full bibliographical index. 

Die Technik der Massage, by Dr. Eeibmayr. A second edition of this 
valuable treatise has just been published in Vienna. Now that massage has 
assumed an emphatic and important position in surgical treatment, the need 
of a manual dealing with the modes of applying massage is evident. The 
present manual is the most complete that has been published upon the sub- 
ject. It deals with all the manifold conditions under which massage may be 
of use, and the surgeon will be especially interested in the chapter on massage 
in chronic joint disease. The book is illustrated by 149 woodcuts. 

Die Neurome, by Dr. Courvoisier (Basle, 1886), is a small but exhaustive 
work on all forms of neuromata. The author divides these growths into the 
following divisions: 1. Those that follow nerve division, including the neuro- 
mata of stumps. 2. The painful subcutaneous tubercle. 3. The neuromata 
of nerve trunks ; and, 4. Those of nerve fibrils. Under each head the pa- 
thology, clinical aspect, and treatment are fully described, and the references 
to the literature of the subject are so complete that the monograph may be 
regarded as one of the most comprehensive of its kind. 

NO CLXXXIII. — JULY, 1886 15 



226 PROGKESS OF MEDICAL SCIENCE. 

Deutsche Chirurgie. The two volumes of this work just issued (Lief. 49 and 
Lief. 50) consist of Milzbrand und Rauschbrand (Splenic Fever and Septic In- 
toxication), by Dr. Koch, and Dr. Breisky's work on Diseases of the Vagina. 
These treatises are among the most important additions to recent surgical 
literature, and no higher praise can be given them than by saying that they 
maintain the character of this remarkable work. 

Two volumes of the Dictionnaire Encyclopedique des Sciences Medicates (Paris, 
1886) have lately appeared (April). The first runs from "Pel" to "Per," and 
contains two papers of surgical interest, one on " Pemphigus," by Dr. Cham- 
bard ; and one on the " Penis," by Drs. Monod and Brun. The latter article 
is the chief contribution in the volume. It deals with the anatomy, deformi- 
ties, injuries, and diseases of the organ. It is a laborious production, and will 
be most valuable on account of the admirable chapter on the injuries of the 
penis. 

The second volume runs from "Tar" to "Ten." The article of most note 
comes under the head of " Tendon," and is written by M. Henocque. Another 
paper— and a very remarkable one — is that on "Tatouage," by Drs. Lacas- 
saque and Magilot. It is difficult to understand how 165 closely printed 
pages could be written upon tatooing, but without being unduly verbose the 
authors have produced a very interesting and in many respects extraordinary 
paper. The matter is illustrated by a number of curious woodcuts represent- 
ing the artistic aspect of tatooing. 

To this list may be added a new edition of Mr. Gant's well-known work, 
A Manual of Surgery, in treatises by various authors, in three volumes, edited 
by Mr. Treves ; Mr. Hutchinson's " Lectures on Syphilis " {British Medical 
Journal, 1886, Nos. 1306, 1308, 1310) ; and Mr. Sutton's "Lectures on Evolu- 
tion in Pathology" {British Medical Journal, 1886, Nos. 1311, 1312, 1313). 

The following recent articles are worthy of notice, although space will not 
permit of their detailed consideration : 

On the Treatment of Intestinal Obstruction by Kussmaul's Method of 
Washing out the Stomach, by Bardeleben [Berliner hlin. Wochens., No. 25). 

On Extirpation of the Kidney, by Bergmann (Ibid., Nos. 46-48). 

Two Cases of Operation for Hydronephrosis in Children, by Rupprecht 
{Ibid., No. 35). 

On the Indications for Nephrectomy, by Braum {Centralblatt fur Chirurgie, 
No. 14, April, 1886). 

On Contusion and Inflammation as Local Predisposing Causes to Cancer, 
by M. Nicaise {Revue de Chir., 1885, No. 9). 

A Monograph on the Causes, Nature, and Treatment of Diphtheria, by 
Dr. Francotte. Leipzig, 1886. 

The Experimental Development of Tubercle in Bone, by Dr. W. Murler 
(Central, filr Chirur., No. 14, April, 1886). 

On Tumors of the Bladder and their Treatment, by Dr. Kuster (Samm- 
lung hlin. Vortrdge, Nos. 267 and 268). 

On the Operative Treatment of Facial Neuralgia, by Dr. Fowler (Annals 
of Surgery, April, 1886). 



SURGERY. 227 

The Fate of Pathogenous Germs in the Body. 

Dr. Eibbert {Deutsche med. Wochenschrift, 31) opens up the question of 
the fate of certain injurious microorganisms after they have entered the body. 
The matter has, up to a certain stage, been investigated by Metschnikoff, and 
a slight account of this work was furnished by Mr. Sutton in his recent Lec- 
tures at the London College of Surgeons (British Medical Journal, Feb. 20, 
1886). Eibbert shows that the infective microorganisms after they have 
entered the body can be destroyed when they are entirely surrounded by pro- 
toplasm, or when entirely enveloped by leucocytes. They are thus cut off 
from all means of obtaining nourishment, and are starved. The investiga- 
tions mainly refer to certain diseases produced by the moulds Aspergillus 
fumigatus and A. flavescens. It is seen that the colonies of germs that are 
surrounded by leucocytes become wasted, indistinct, and altered in their 
capacity for staining. This mode of destruction does not apply to all infec- 
tious diseases. In splenic fever and in tuberculosis the cells of the organism 
do not appear to be powerful enough to put an end to the process. Eibbert 
also points out with what facility and in what great quantity infective germs 
may be evacuated by the kidney. He thinks that this is the chief mode of 
disposal in most infectious disorders. He points out, however, that the germs 
passing through the kidney may be arrested there, and may form a focus for 
a new invasion of the body. 

Nerve Suturing. 

Mr. Eeginald Harrison (British Medical Journal, March 6, 1886) reports 
the following case : A man, aged twenty-one, received a severe cut across the 
front of the wrist. The ulnar and median nerves were divided. When seen, 
eighteen months afterward, all parts in the hand supplied by those nerves 
were paralyzed. The nerves were exposed, and their ends freshened and 
united by catgut. In the course of eighteen months the nerve supply of the 
parts was completely reestablished, and the patient had a useful limb, which, 
however, still showed a little impairment of motion and sensation. 

In connection with this subject a valuable and exhaustive monograph has 
been recently published in Leyden, by Dr. Koppeschaar (Nervennaht und 
Nervenneubildung). The histology of nerve healing is well described, the 
literature of the subject amply given, and the paper illustrated by five very 
interesting cases. A good case of suturing of the musculo-spiral nerve is also 
given by Hoffmann (Deutsche med. Wochenschrift, No. 27, 1885). 

Surgical Treatment of Empyema. 

Dr. Maclaren, of Carlisle, in the British Medical Journal for April 3, 1886, 
gives an account of the following operation : A lad, aged seventeen, developed 
left-sided pleurisy in May. In June seventy ounces of clear fluid were drawn 
off. In August ten ounces of pus were evacuated. In the following March, the 
punctures made were still discharging pus, and in July portions of the fifth, 
sixth, seventh, eighth, ninth, and tenth ribs were removed in segments vary- 
ing in length from two and three-quarters inches to one inch. The cavity 
continued to discharge until June in the next year, when the patient is re- 



228 PBOGKESS OF MEDICAL SCIENCE. 

ported as "quite well." The treatment, therefore, extended over three years. 
Dr. Maclaren concludes the paper with some valuable remarks upon the 
general treatment of empyema by surgical means. 



Compression of the Innominate Artery. 

Prof. Annandale, in the Lancet for March 13, 1886, considers this subject 
under two heads: 1. Temporary compression of the artery in connection with 
prevention of hemorrhage in operations or injuries involving its main branches. 
2. More permanent compression of the same vessel in connection with the 
treatment of aneurisms involving the same branches. 

1. For temporary compression he advocates the following method: An 
incision, two inches long, is made in the middle line of the neck just above 
the sternum. The trachea is exposed, and then, by a careful separation of 
the tissues, the posterior aspect of the artery can be exposed, and the vessel 
compressed against the sterno-clavicular articulation. The compression may 
be effected by the finger, or by a special clamp, one blade of which fixes the 
artery, while the other takes its hold upon the front of the sternum. 

This method is the application to the innominate of the procedure adopted 
by Syme for other cervical vessels before dealing with aneurisms of the neck 
or axilla by the "old method." 

2. Prof. Annandale's proposed method in a case of subclavian aneurism is 
this : 1. To expose the innominate artery by means of the incision just named 
under antiseptic precautions. 2. To insert one end of an India-rubber drain- 
age tube under the artery, and leave it there in position until the tissues had 
become accustomed to its presence. 3. To introduce the small blade of the 
clamp described into the drainage tube and carry on more or less continuous 
compression. The measure is illustrated by one case only. The patient, a 
man aged fifty-three, was admitted with a subclavian aneurism. The incision 
was made, and the drainage tube inserted on May 27th. Before the second 
step in the procedure could be adopted the patient died (June 8th) of hemor- 
rhage from the innominate artery. 

On Rectal Exploration in Cases of Hip Disease. 

Dr. Schmitz, of St. Petersburg, in Centralblatt fur Chirurgie for March 13, 
1886, points out that by examination through the rectum the pelvic aspect 
of the acetabulum may be fully explored. It is well known that coxitis often 
commences in the acetabulum, and probably not unfrequently in the Y-shaped 
cartilage in its floor. The diagnosis of the seat of the trouble may therefore 
be aided by the measure proposed. He gives the following cases : Male, aged 
three, symptoms of hip disease ; gluteal abscess ; prominence of third lumbar 
spine ; rectal examination revealed a swelling in region of acetabulum ; gluteal 
abscess opened ; it led into hip-joint ; acetabulum perforated. It is probable 
here that the trouble commenced in caries of the lumbar spine, and that the 
abscess resulting therefrom found its way into the hip-joint. 

Male, aged five, Pott's disease of spine ; hip disease ; gluteal abscess ; pre- 
cisely the same perforation of the acetabulum with tumor felt via rectum as 
in previous case. 



SURGERY. 229 

This also was probably a case of spinal abscess burrowing into the hip-joint. 
Male, aged five, hip disease twenty-one months ; gluteal abscess, the size of a 
hen's egg, felt through the rectum ; pain on defecation ; perforation of the 
acetabulum discovered as in the other cases. Arthrectomy was performed in 
each instance, and a good recovery resulted. 

On the Treatment of Hip Dislocations Complicated by Fracture 
of the Neck of the Femur. 

Dr. Wippermann, in Archivfiir Win. Chirurgie, Bd. 32, p. 440, commences 
his observations with this case : A woman, aged thirty-four, was struck by a 
falling piece of timber, and fell to the ground. The result was a dislocation 
of the left femur. It was not treated. In fourteen days she began to walk 
with a crutch. In three months she came under the author's notice. She 
was very lame, and a dislocation onto the dorsum ilii was detected. In 
attempting reduction under chloroform, the neck of the femur was broken, 
but the luxation not reduced. In due course a gluteal abscess formed. This 
was opened, and the head of the femur, loose and necrosed, removed. The 
patient made a very fair recovery. Dr. Wippermann has collected no less 
than thirteen cases of dislocation at the hip-joint, associated with a fracture 
of the neck of the femur. In one-half of the cases the fracture was produced 
by the attempts made at reduction. These various cases are analyzed in 
detail. The results of this examination, so far as the treatment is concerned, 
are as follows : 1. If the fracture be due to the accident, and have followed 
upon the same lesion that produced the dislocation, attempts should be made 
to obtain union of the broken bone. 2. If the fracture be due to attempts at 
reduction, and be extracapsular, attempts should be made to obtain union. 
3. If the fracture be due to attempts at reduction, and be intracapsular, the 
head of the femur should be resected, as it will, if left, necrose. The author 
does not discuss the propriety of establishing non-union in the fracture in 
order to provide freer movement about the hip. 

Acute Myositis. 

Prof. Scriba, of Tafrau, in Centralblatt fur Chirurgie, No. 8, 1886, has 
reported four cases of this peculiar affection. It consists of a multiple inflam- 
mation of striated muscle. The affected muscle becomes hard, tender, swollen, 
and useless. The symptoms develop suddenly, and in each case followed 
some slight suppurative trouble, either in the skin or the mucous membrane. 
The author believes that this affection is of the same character as acute osteo- 
myelitis — i. e., that it is a disease of an infective type, and that the micro- 
organisms are derived from the primary suppurative centre. 

The prognosis is good. The inflammation usually subsides without compli- 
cation — even when suppuration occurs healing readily takes place after the 
pus has been discharged. 

Aneurism of the Abdominal Aorta. 

Dr. Liebrecht has produced a monograph on aortic aneurism (Liege, 
1885), of some value. The work commences with an account of a case under 



230 PROGKESS OF MEDICAL SCIENCE. 

the care of Prof. Loretta, and concludes by a review of all the published 
records of ligature of the abdominal aorta. The following is Prof. Loretta's 
case : A sailor, aged thirty, who had had syphilis when twenty-five, received 
a strain in June, 1884. This was followed by abdominal pain. In three 
months the man was unable to walk, and soon took to his bed. A pulsating 
tumor was discovered in the abdomen about the points of origin of the coeliac 
axis and superior mesenteric arteries. An incision was made from the xiphoid 
cartilage to the navel, and the tumor exposed with difficulty ; it was the size 
of the head of a newly born child. Loretta introduced a canula into the sac, 
and through it inserted two metres of silvered copper wire, half a mm. in 
thickness ; no bleeding followed, and the parietal wound was closed ; a rapid 
improvement followed. In eighteen days the tumor was only one-third its 
original size. In four weeks it was one-fourth its size, and had ceased to pul- 
sate. In seventy days the man was discharged cured. Ten days later he 
died suddenly, and the autopsy revealed a complete cure of the aneurism with 
a rupture of the aorta just below the obliterated sac. Loretta ascribes this 
rupture to atrophy of the vessel produced by the presence of the aneurism in 
conjunction wiith syphilitic disease of the aortic walls. 

A New Method of Reducing Hernia. 

Dr. Nikolaus, in Centralblatt fiir Chirurgie for Feb. 6, 1886, proposes the 
following method in place of taxis : He points out that in reducing a strangu- 
lated or incarcerated hernia the end can be much more readily obtained by 
traction from within the abdomen than by pressure applied without that 
cavity. He cites cases where taxis had failed during life, but where after death 
the gut was readily reduced by dragging upon it after the abdomen had been 
opened. He draws attention to the frequent failure of taxis, and supports his 
arguments with reference to traction upon a series of experiments with gut 
held in an artificial opening. After reviewing the various plans of reduction 
by posture, he advises that the patient be placed in the knee and shoulder 
position. Both knees rest upon the bed, the femora are kept in the vertical 
posture, and the shoulder of the sound side is supported also upon the couch. 
Before this posture is assumed the bladder and rectum may be emptied, and 
while it is maintained gentle pressure may be kept up on the swelling. The 
position may be persevered in for twenty or forty minutes, or longer. Dr. 
Nikolaus maintains that it relieves the circulation in the strangulated part, 
that it reduces the intra-abdominal pressure, and causes the weight of the mass 
of intestines to act by traction upon the segment of gut retained. 

He gives cases to show that this method has succeeded after taxis under 
chloroform has failed. The procedure is certainly more reasonable than that 
by taxis, and is worthy of extended trial. The author thinks that it is of no 
use in cases of internal strangulation. 

Flat-foot. 

Prof. Humphry has contributed an interesting paper upon this subject 
{Lancet, March 20, 1886). The article deals so entirely with matters of detail, 
that an abstract that would be of any value is scarcely possible. The author 
commences with an account of the mechanism of the foot and the construe- 



SURGERY. 231 

tion of the plantar arch. This account represents that usually accepted at 
the present day, but Prof. Humphry has added many points to the elucidation 
of the subject, and the demonstration is very clear. Then follows a descrip- 
tion of a recently dissected case of flat-foot, which description is without doubt 
the best that we possess. 

The article should be read in conjunction with Mr. Symington's paper on 
"Flat-foot " in the nineteenth number of the Journal of Anatomy. 

An elaborate contribution on "Flat-foot and Club-foot" (Beitrdge zur Lehre 
vom Klumpfusse und vom Plattfusse) has also been recently published in Berlin 
by Dr. Eoser, of Marburg. 

Drainage of the Bladder. 

Mr. Howlett, in the British Medical Journal for February, 1886, advocates 
continuous drainage of the bladder in the following conditions (among others) : 
chronic cystitis, enlarged prostate, atony of the bladder, paralytic retention, 
ruptured urethra, impassable stricture, malignant disease of the prostate or 
bladder, and as a preparation for plastic operations upon the urethra. He 
then reviews the various methods by which such drainage could be carried 
out and discusses the suprapubic, rectal, prostatic, and interpubic puncture, 
and the opening of the membranous urethra. He points out the objections 
that may be urged against these procedures, and claims an advantage for his 
own operation which he terms the postprostatic. To perform the operation, 
the patient is placed in the lithotomy position, and the forefinger of the left 
hand is passed into the rectum until the region of the trigone is reached. A 
trocar and canula of the size of a No. 12 catheter is thrust through the skin 
about three-quarters of an inch in front of the anus and slowly pushed on 
until resistance is felt to have disappeared. The bladder is then emptied and 
a suitable tube fixed in situ. The following appear to be the risks of the 
proceeding : urinary extravasation behind the deep pelvic fascia, injury to 
the vesiculse seminales or to the peritoneum. Mr. Howlett records two cases, 
in both of which the operation was followed by satisfactory results. 

On the Cause of Hypertrophy of the Prostate. 

Mr. Keginald Harrison has contributed an important paper upon this 
subject [Lancet, March 6, 1886). The points upon which the author lays 
special stress are these. The interureteral bar of muscular fibres is very usu- 
ally met with in cases of enlarged prostate, and is obviously the result of 
muscular hypertrophy. A depression of the trigone may exist previously to 
the prostatic enlargement, and a condition of residual urine may precede 
rather than result from the increase of the gland. The trigone, or floor of 
the bladder, is peculiar in that it contains but few muscular fibres. Muscle 
in abundance may be found in the bladder as low as a line corresponding 
with the openings of the ureters and marking the superior boundary of the 
trigone, and again abundance is found below in the prostrate. Between these 
two points the power of muscular contraction can hardly be said to exist. 
Assuming that, from any cause, such as a long retention of urine, habit, posi- 
tion of the body, or the weakness connected with advancing years, the trigone 
or non-contractile part of the bladder becomes permanently depressed or 



232 PEOGEESS OF MEDICAL SCIENCE. 

altered in form, so that the person finds himself unable to get rid of the last 
half ounce or so of urine ; the effect will be frequently repeated expulsive 
efforts in all the muscles immediately adjacent to a part which, by reason of 
its connections and structure, has no power of exercising contractibility. 
Mr. Harrison believes that this will eventually lead to hypertrophy of the 
muscular fibres between the orifices of the ureters — the interureteral bar — as 
well as of the muscular fibre that enters so largely into the structure of the 
prostate. Mr. Harrison supports his view by reference to clinical data and to 
the behavior of the prostate after such operations as have rendered the act of 
micturition purely mechanical. The author fails, we think, to show how the 
prostate, situate as it is below the depressed trigone, can empty the bladder 
of urine that is lodged above it, and why the hypertrophy of the bladder 
should attack especially the interureteral tissue. The paper is, however, most 
suggestive, and as the work of the chief authority in England upon the sub- 
ject, it demands attention. 

Tubercular Disease of the Genitourinary Organs in the Male. 

The points raised by Dr. Steinthal (Virchow's Archiv, Bd. c. p. 81) in a 
paper upon this subject are these. In cases of extensive tubercular disease 
of the urinary passages does the trouble spread downward from the kidney, 
or does it commence in the urethra and spread upward through the bladder 
and ureters to the renal pelvis? And, secondly, what part does tubercular 
disease of the testis play in connection with this matter? 

Dr. Steinthal's answers to these questions are based upon the data of twenty- 
four cases. He thinks that in extensive disease the trouble usually com- 
mences in the kidney and spreads downward, and that spreading in an 
ascending direction is quite uncommon. He believes tuberculosis of the 
testis to be usually the outcome of a solitary deposit, and to be, with very few 
exceptions, primary. It is to be noticed also that tubercular mischief spread- 
ing from the kidney will follow the urinary passage and will not advance to 
the testicle. 

Operations on the Stomach. 

Dr. Hacher has published an account of the circumstances and the fate 
of the patients subjected to operations on the stomach in Professor Billroth's 
clinic from 1880 to March, 1885. (Vienna, 1886.) Thirty-three operations 
were performed, with thirteen recoveries and twenty deaths. 

1. Gastrotomy. One case (recovery) for the removal of false teeth that had 
been swallowed. The indications for gastrotomy are given and the details of 
the operation are fully described. Gastrotomy in connection with Loretta's 
operation is also considered. 

2. Gastrorrhaphy (the operation for the closure of openings in the stomach). 
Two cases are given: one of perforation of the stomach, and one of pene- 
trating wound from a revolver bullet. Both were fatal. This operation 
would appear to have no prospect of success unless performed very early. 

3. Gastrostomy. Four cases : three for cancer of the gullet, and one for 
cicatricial stricture of that part. The latter patient recovered. The others 
died, although one of them lived for one and a half months. Billroth is not 



SURGERY. 233 

greatly in favor of this operation in cases of cancer. He thinks it should be 
performed for the purpose merely of prolonging life, and should not be under- 
taken until the swallowing of fluids has become quite impossible. 

4. Gastrectomy (the operation for the removal of portions of the stomach, 
pylorectomy). Eighteen cases are given, with ten deaths. Fifteen of these 
patients were the subjects of pyloric cancer, and of this number eight died. 
They are placed in three very convenient classes. No. 1. Cases where no 
adhesions existed and the glands were free. Two patients came in this 
division. Both recovered, and were alive respectively two and four years 
after the operation. No. 2. Cases where slight adhesions had formed, and 
where a moderate gland implication was noted, eight patients. Five only 
survived the operation, and these died at periods of four months (two), of eight 
and a half months, of ten months, and a year. In two of these, gastro- 
enterostomy had been performed. No. 3. Cases where extensive adhesions 
were found, and where metastases existed. Five patients came under this 
division. They all died very soon after the operation. 

5. Gastroenterostomy (the operation of establishing a fistula between the 
stomach and jejunum in cases of pyloric cancer). Nine operations were per- 
formed. Five of the patients died from the operation ; four survived, and 
died at the end of two months (two cases), four months, and one year. In 
the two last mentioned cases, gastrectomy had been performed. 

The paper gives a full account of the technique of the various procedures, 
and forms a complete treatise upon the subject of gastric surgery. 

On the Treatment of Peritonitis by Laparotomy. 

This mode of treatment has now become very generally applied, and has 
been attended with considerable success. The following recent papers are 
the more important: Professor Studensky (Centralbl. f. Chirurgie, No. 10, 
1886). A girl, aged twelve, developed a purulent effusion in the peritoneal 
cavity on the nineteenth day of typhoid fever. She was emaciated; the 
abdomen was much swollen and very painful. By aspiration, six pounds of 
pus were removed without benefit. Four days after, laparotomy was per- 
formed, and six pounds of pus again evacuated. The peritoneal cavity was 
washed out with a four per cent, boroglyceride solution, and drained. Ke- 
covery was retarded by an encysted collection, which in time discharged, and 
the patient left her bed in three and a half months. 

Dr. Natjmann (Centralbl. f. Chirurgie, No. 2, 1886) records four cases of 
diffused tubercular peritonitis treated by laparotomy. The patients were 
women, varying in age from twenty-three to fifty-six. One case was of 
doubtful character. It was a localized peritoneal collection of some kind, but 
its tubercular character was not established. The patient recovered rapidly 
after the laparotomy. In the three remaining cases there is no doubt that 
the trouble was due to tubercular disease of the peritoneum. The peritonitis 
was of slow progress, and attended with emaciation and considerable ascites. 
One patient had already phthisis. Of these three laparotomies, one only 
ended in recovery. 

M. Chavasse (Bull, et mem. de la Soc. de Chir., Paris, t. xi. p. 123). A man 
aged twenty-three received two kicks upon the abdomen from a horse. He 



234 PROGRESS OF MEDICAL SCIENCE. 

commenced to vomit two hours afterward, and on the third day acute general 
peritonitis set in. Laparotomy was at once performed, but the patient died. 
The autopsy revealed two contusions of the transverse colon, rupture of one 
of the mesocolic arteries, hemorrhage into the jmncreas, but no perforation 
or extravasation. 

Dr. Valerani (Gazz. delle cliniche, Nov. 24, 1885). A woman aged thirty- 
three came under treatment for chronic general peritonitis, following para- 
metritis. She suffered from constipation, vomiting, and abdominal pain. 
The abdomen was distended, and there was much ascites. The pelvis ap- 
peared to be entirely occupied by a resistant swelling. Laparotomy was 
performed. The pelvic mass proved to be composed of an extraordinary 
fibrinous exudation. It was as firm as gelatine, and readily gave way under 
the fingers. A like collection occupied all the lower part of the abdomen. 
This material was taken away, so far as was possible. The abdominal cavity 
was washed out with a boracic solution and drained. The patient made a 
rapid recovery. 

Dr. J. Mikulicz has published a valuable paper (Sammlung Jclin Vortrage, 
No. 262) on laparotomy in perforations of the stomach and bowels. He 
includes not only his own cases that have been already published, but all 
other recorded cases up to the present time. He deals with the difficulties of 
diagnosis and the questions affecting early operation. The paper includes 
the question of laparotomy in gunshot wounds, in typhoid ulceration, in 
gangrenous hernia, and in typhlitis; the author is opposed to any interference 
in tubercular peritonitis. The details of the operation are fully described. 



In America. 

under the charge of 

E. J. HALL, M.D., 

OF N£W YORK. 



Tracheotomy for Pseudo-membranous Laryngitis. 

In the Medical Record of April 3, 1886, Dr. Kobert W. Lovett gives an 
analysis of seventy-seven cases of tracheotomy for pseudo-membranous laryn- 
gitis, performed at the Boston City Hospital during 1885. The ages of the 
children varied from nine months to seven years. Twenty recovered, twenty- 
five died with septic symptoms, twenty-six with symptoms of extension of the 
membrane to the trachea and bronchi, four of heart failure during or after 
operation, and one each of pneumonia and peritonitis. The percentage of 
recoveries does not differ materially from the well-known thirty per cent, cal- 
culated from thousands of cases. 

Besides a number of other interesting clinical observations, the special value 
of the report lies in the statement that in the twenty-six cases dying by exten- 
sion, death was preceded by frightful and gradually increasing dyspnoea, far 
more prolonged and painful than in the cases where tracheotomy was not per- 
formed. In these cases, therefore, the operation was not a means of eutha- 
nasia, but the contrary. 



SUKGEEY. 235 

Intubation of the Larynx in Fifteen Cases of Diphtheritic 

Croup. 

Three cases are reported in the Medical Record, April 10, 1886, by Dr. 
Dillon Brown, Eesident Physician of the New York Foundling Asylum, to 
illustrate the value of the tubes devised by Dr. James O'Dwyer, to be introduced 
into the larynx as a substitute for tracheotomy. The results, as regards relief 
of dyspnoea, seem to have been more satisfactory than in the cases of trache- 
otomy reported above, and if the introduction and retention are really as easy 
as claimed, the method may largely supplant the cutting operation in this class 
of cases. The whole tube lies in the larynx and trachea ; the lower extremity 
extends to a point about half an inch above the bifurcation of the trachea, 
while the upper end rests upon the " ventricular bands." 



Laparotomy in the Treatment of Penetrating Wounds and 
Visceral Injuries of the Abdomen. 

Professor F. S. Dennis read an article on this subject before the New 
York County Medical Association ( The Medical News, February 27 and March 
6, 1886), which is undoubtedly destined to give a great impulse to the prac- 
tice of early operative interference in this class of cases. 

The injuries are divided into three classes : 

1. Penetrating stab wounds. 

2. Penetrating gunshot wounds. 

3. Rupture of the intestine. 

Under the first heading, a number of instructive cases are given, illustrating 
the benefits of operation, or the dangers of delay. In one of these, where 
wound of the intestine was suspected, laparotomy was performed, the whole 
abdominal contents carefully examined, and no wound being found, they 
were replaced, and the abdomen closed, the patient making a good recovery. 

While almost all surgeons will agree with Prof. Dennis as to the propriety, 
or, indeed, the imperative necessity for immediate laparotomy in cases where 
there is even a strong presumption that the intestinal canal has been perfo- 
rated, there will be much hesitation in accepting his advice to explore in all 
cases of penetrating wounds of the abdomen. Prof. Dennis unquestionably 
very much underrates the dangers of such an operation. 

As Dr. Weir remarked, during the discussion at the New York Surgical 
Society, on Dr. Bull's successful case of laparotomy for bullet-wound, it is 
quite unjustifiable to compare the operation of exploratory incision for 
abdominal tumors with the same operation for suspected perforation of 
the bowel. In the former, a small incision, and the introduction of two or 
three fingers for a few seconds by the operator, usually suffice. In the latter, 
the abdomen must be widely opened, its whole contents inspected, and often 
the entire length of the alimentary canal passed through the hands of the 
operator. A case, indeed, is said to have occurred in the city, in the hands of 
a competent surgeon, where a similar operation was performed, no injury of 
the viscera being found, but the patient died of peritonitis. It is to be remem- 
bered, also, that in such cases the surgeon has to bear all the odium of 
having directly caused the death of the patient by an unnecessary operation. 



236 PROGRESS OF MEDICAL SCIENCE. 

Case VI. is one of extreme surgical and pathological interest. A penetrating 
wound of the abdomen, without wound of the intestine, was followed by a 
volvulus, causing strangulation fatal in about forty-eight hours. The volvulus 
is attributed to the sudden violent peristalsis, and, Prof. Dennis thinks, may 
be a not very rare occurrence. 

In the resume of successful cases of penetrating stab wounds, "where either 
a true laparotomy was performed, or the original wound was enlarged, the 
perforations sutured, and the cavity sponged," it is perhaps unfortunate that 
these two very different sets of cases should be put together, as it might readily 
convey a too favorable impression of the results in the operation really under 
consideration — that of laparotomy. Thus if we examine Prof. Dennis's four 
successful cases, only one is a true laparotomy, and no wound of the bowel 
was found; one is a wound of the abdomen, with protrusion of intestine, and 
two wounds of the protruded parts — suture of the wounds, enlargement of 
abdominal wound, and return of the bowel ; the third case is a mere protrusion 
of the intestine without wound ; and the fourth appears to have been omitted 
from the report ; while the two cases of laparotomy for stab wound both died. 
Two cases of laparotomy for gunshot wound also terminated fatally, from 
hemorrhage. 

The most valuable part of the article is, undoubtedly, that on rupture of 
the intestine due to traumatism ; the diagnostic symptoms are well discussed 
and merit careful study. In the description of the technique of the operation 
we miss any discussion of the propriety of draining an infected peritoneum, 
instead of relying on the generally unsuccessful attempt at disinfection by 
antiseptic solutions. 

Permanent Drainage in Ascites. 

Dr. Aug. G. Caille read a paper on this subject before the New York 
Academy of Medicine ( The Medical News, February 13, 1886). Two cases were 
related in full : the first patient, an elderly man, suffering from cirrhosis of 
the liver, had already been tapped nine times. Instead of merely resorting 
to another tapping, Dr. Caille inserted a short drainage tube through an in- 
cision below the umbilicus, and applied antiseptic dressings as required. At 
first two to three pints of fluid were evacuated daily, but the quantity grad- 
ually diminished, and finally the discharge ceased altogether. The general 
oedema and other distressing symptoms disappeared entirely. No bad results 
followed the operation, except an eczema, due to the constant moisture, and 
readily overcome by protecting the skin. The patient was enabled to go about 
attending to his usual occupations for nine months, and entirely comfortable. 
He died finally of heart failure, the ascites and general anasarca not having 
returned. On post-mortem, cirrhosis of the liver was found, and there was 
no evidence of peritonitis at the point where the tube had been inserted. 

The second case, also one of cirrhosis of the liver, and in a very bad con- 
dition before operation, was also completely relieved, and lived in comfort 
for a considerable time, dying finally of heart failure. No autopsy was ob- 
tained. Dr. Caille then discussed the symptoms most troublesome and 
dangerous in ascites : the collateral circulation in cirrhosis of the liver ; the 
ways in which relief of abdominal pressure might be expected to act ben en- 



SURGERY. 237 

cially, and the best means of accomplishing this, giving a number of sugges- 
tions as to technique, and recommending strict antiseptic precautions, though 
stating that the peritoneum under such circumstances is well known to be less 
susceptible to infection than in the normal condition. 

During the discussion which followed, Dr. Jacobi narrated two additional 
cases. In one, laparotomy was performed for supposed ovarian cyst, and only 
ascites found. A drainage tube was inserted and left in place for six weeks, 
giving entire relief, which, however, was only temporary, as the ascites re- 
turned. The second case was one of cirrhosis of the liver, and the operation 
was performed after hearing of Dr. Caille's method. Some improvement fol- 
lowed, but the patient finally died of exhaustion. Dr. Jacobi also called 
attention to the fact that great relief is not infrequently afforded by the forma- 
tion of a spontaneous fistula. 

In these days of activity in abdominal surgery, it is safe to say that Dr. 
Caille's suggestion will be eagerly adopted and thoroughly tested. It would 
be premature to attempt a final judgment until a much larger number of 
cases is at our disposal ; but that the operation may not fall into undeserved 
disrepute through a failure to realize irrational expectations, it will be well 
to remember that results such as Dr. Caille's can only be expected where the 
circulation through the liver can be partially reestablished, or a considerable 
collateral circulation exists ; and that, in regard to the extent of the possible 
collateral circulation, very wide differences exist between individuals. Further, 
we must remember that, although the peritoneum in ascites does not readily 
become inflamed, yet general peritonitis after mere puncture is not very rare, 
and that it is difficult, or often even impossible, to maintain an aseptic con- 
dition when the dressings are constantly soaked through by an albuminous 
fluid. 

On Spontaneous Phlebacteriektasia of the Foot. 

In The Medical News for March 20, 1886, Dr. A. G. Gerster, reports two 
cases of this very rare condition, seen in the German Hospital, N. Y. The 
patients were boys, aged fourteen and eighteen respectively, and the disease 
dated from infancy in each. The older patient declined operation, and was 
lost sight of. The other presented a doughy, soft, nodular swelling, of irregu- 
lar and not well-defined outline, on the dorsum and sole of the left foot, and 
in the dorsum of the foot along the course of the saphenous nerve a series of 
roundish, irregular, rather hard, dark blue, partly confluent nodes, surrounded 
by enlarged veins. There was an arterial bruit and pulsation over the tumor; 
the foot was generally hypertrophied, and had a higher temperature than 
the right ; on its dorsum were a number of intractable ulcers. No other ab- 
normalities existed, except unusually strong pulsation of both femorals, and 
enlargement of the heart, with increased energy of the heart-beat. 

Amputation being refused, and elastic pressure having failed, the super- 
ficial femoral was tied in Scarpa's triangle, and ten minutes later, pulsation 
having returned, a ligature was applied to the external iliac. Pulsation 
ceased, but for some time the nutrition of the limb was very poor, and the 
belly of the peroneus longus and two toes actually became gangrenous, and 
were removed. Six months later the patient returned, pulsation being as 



238 PROGRESS OF MEDICAL SCIENCE. 

marked as before, and the foot in bad condition. A successful Pirogoff's 
amputation removed the diseased parts. 

A reference is given to the very few previously reported cases. 

Considering the very discouraging results in the cure of cirsoid arterial 
tumors by ligature of main vessels, and the great danger of gangrene from 
the application of a second ligature at a higher point, after the ligature of a 
large trunk, we may very well question the advisability of the first operation, 
especially as there was no special urgency to justify so great a risk. 



OPHTHALMOLOGY. 



UNDER THE CHARGE OF 

CHARLES STEDMAN BULL, A.M., M.D., 

LECTURER ON OPHTHALMOLOGY IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, SURGEON TO THE 
NEW YORK EYE AND EAR INFIRMARY. 



A New Operation for Congenital Ptosis and Paralytic Ptosis. 

Panas begins his paper in the Arch. d'Ophthal., for January and February, 
1886, by a description of the objects which an operation is desired to produce. 
In all operations the shape of the lid is to be considered, which will result 
from the operation. As in these cases the levator muscle is absent or para- 
lyzed, it must be replaced by that muscle which is its physiological aid — the 
occipito-frontalis, as without this substitution the lid, rendered shorter and 
even corrected in its form, would be inert and unable to be lifted voluntarily 
as in the normal state. Hence the necessity of effecting a close union between 
the movable part of the lid and the free end of the frontal muscle. 

Panas's method of operating is as follows : The lid is put upon the stretch 
over a broad horn spatula, while an assistant presses his hand upon the fore- 
head, so as to fix the tissues firmly against the bone and prevent their being 
pulled downward by the operator. The surgeon then makes a horizontal curved 
incision, with the concavity downward, from one commissure to the other, but 
interrupted in the centre for a distance of eight millimetres. This incision 
follows the upper border of the tarsus, which corresponds to the region where 
the tendon of the levator blends with the suspensory ligament. From the 
internal end of the outer incision and the external end of the inner incision, 
run two vertical and parallel incisions upward to the groove separating the 
lid from the eyebrow. Another horizontal incision, two centimetres long with 
the concavity downward, unites these two vertical incisions, and should extend 
through all the soft parts as far as the periosteum of the orbital margin. The 
small median flap is then dissected from above downward, as well as its ciliary 
base, passing between the orbicular muscle and the tarsus, care being taken to 
avoid the suspensory ligament of the lid. Finally a curved incision, parallel 
to the preceding, is then made just above the eyebrow, and three centimetres 
long, through the skin and supraciliary muscle down to the periosteum. The 



OPHTHALMOLOGY. 239 

musculocutaneous bridge comprised between these last two incisions is then 
carefully dissected up, avoiding the suspensory ligament of the lids and 
the frontal periosteum. It is then drawn downward, and the lid is slipped 
under it until the bleeding flap is brought in contact with that of the skin of 
the frontal bone and divided frontal muscle, and here it is fixed by three 
sutures. As the traction here exerted might produce ectropion of the lid, 
two other lateral sutures are introduced, which include the suspensory liga- 
ment and the conjunctiva, but exclude the skin and are fixed in the superior 
lip of the supraciliary incision. The lid is thus lifted directly upward, while 
the shape of the palpebral aperture is not altered. The sutures may be 
removed on the fifth or sixth day, but the bandage should be retained until 
the scar has become firm. At the end of six weeks the ptosis is permanently 
corrected. 

The Artificial Cornea. 

Martin, in the Recueil d' Ophthal., for February, 1886, proposes a modifi- 
cation of the operation which has for its object the insertion of an artificial 
cornea. He proposes to rotate the eyeball on its antero-posterior axis a 
quarter of a circle inward toward the internal canthus. He advances the 
insertion of the internal rectus muscle as far as the corneal margin, thus pro- 
ducing a convergent squint. The leucoma of the cornea is thus turned 
inward, and the sclerotic forms the field for operation. Two weeks later he 
introduces beneath the conjunctiva, in the horizontal plane of the eye, and 
about six millimetres from the cornea, a small gold, semi-cylindrical nail 
with large head and pierced by an opening eight-tenths of a millimetre in 
diameter. When the eye has become accustomed to the instrument, eight or 
ten days afterward, he removes the obturator of the cylinder, and light at 
once enters the cavity of the eye. The conjunctiva is the obturating mem- 
brane, and this he removes by means of the galvanocautery. 

Sympathetic Keratitis following Destruction of an Eye from 

Injury. 

Eolland, in the Recueil d'Ophthal., for March, 1886, reports a case of this 
kind occurring in a man aged fifty-four, who was suffering from an intense 
panophthalmitis of the right eye, following an injury from a piece of steel. 
Enucleation was proposed, but the patient refused, and would only allow 
Eolland to make a free incision into the inflamed eyeball. For five years 
the patient complained constantly of severe pain in the stump, but without 
any signs of sympathetic trouble. Five years and eight months after the 
accident the patient was brought to Eolland with a still painful stump on 
the right side and only quantitative perception of light in the left eye. The 
entire cornea was infiltrated, and in the inferior temporal quadrant there was 
a small ulceration. Photophobia, lachrymation, and marked conjunctival 
injection were present, and there was some pain. The stump of the right 
eye was at once removed* and ten days later the cornea of the left eye had 
entirely regained its transparency, and the ulcer had completely healed 
without any treatment to this eye. Vision was restored to the normal 
standard. 



240 PROGRESS OF MEDICAL SCIENCE. 

A Case of Sympathetic Inflammation Cured without Enucleation 
of the Fellow Eye. 

Hoffmann {Kl. mon. fur Augenheilk., April, 1886) reports an interesting 
case of this kind following an extraction of cataract. The extraction was a 
perfectly normal operation, without any prolapse of the iris. Four or five 
weeks later, when there were traces of cortex still visible, a serous iridocyclitis 
developed, which lasted for some weeks and ended in closure of the coloboma 
iridis by a membranous exudation. Seven months after the extraction, when 
the eye had become perfectly quiet, an attempt was made to make a new 
pupil, which was followed by sympathetic inflammation of the other eye in 
the form of a serous iridocyclitis, while the eye on which the operation had 
been done remained perfectly quiet. The inflammation subsequently changed 
its character and became a severe type of exudative cyclitis, with periods of 
retrogression and exacerbation, which, however, finally ended under the 
ordinary application of heat, atropia, and small doses of quinine, and eventu- 
ally an iridectomy upward. Eighteen months later, an extraction of cataract 
was made on this eye by Sattler, with a relatively excellent result. 

The Etiology of Glaucoma. 

Schoen has of late years observed (Arch./. Ophthal., xxxi.4) that the cases 
of acute glaucoma w T hich came to him for operation, were all either hyper- 
metropic, or were patients with hypermetropic astigmatism, and that when 
only one eye of a patient was the seat of glaucoma, it was the more hyperme- 
tropic of the two. These facts led him to think that both simple and acute 
glaucoma might be regarded as diseases of the accommodation. He raises for 
consideration the following questions: 1. Can the fibres of the ciliary muscle 
through their tendons exert any mechanical strain upon the prolongation of 
the sheath? 2. Can a mechanical distortion of the prolongation of the sheath 
be transmitted through the medium of the laminated fibres to the fibres of the 
optic nerve and the intervening tissues ? 

Careful investigations have shown him that there is developed in eyes which 
have been long subjected to great accommodative strain, a more or less pro- 
nounced excavation of the optic disk, which is called accommodative. The 
ciliary muscle may through its tendon exert a strain upon the prolongation of 
its sheath, and this strain is transmitted to the interior of the optic nerve. 
This accommodative excavation may be the first stage of simple glaucoma. 
Further investigations have shown that the action of the ciliary muscle results 
in an increase in the vitreous tension within the external zonula ring. In the 
anterior chamber the act of accommodation diminishes this tension. The 
lens, pushed forward by the increased pressure in the vitreous, must in some 
w r ay be held back, or the tension in the anterior chamber would be increased, 
but of this there is no demonstrable proof. Hence, the factor which holds 
the lens back must be sought in the lens itself, and must depend upon an in- 
creased tension of the external leaf or lamina of the zonula. Microscopical 
examinations have convinced Schoen that the ciliary body and processes have 
imposed upon them the task of holding back the lens, and he assumes that 
the anterior leaf of the zonula has a concave curvature forward. He assumes 
that the inflammatory adhesion of the iris to the anterior surface of the ciliary 



OPHTHALMOLOGY. 241 

body and to the cornea, met with in glaucoma, is a secondary process, and the 
pressing forward of the lens is apparently the cause of these changes. 

Schcen presents his theory of the causation of acute glaucoma as follows : 
The etiological factor of the acute glaucomatous process lies in a functional 
relative insufficiency of the circular fibres and of the inner and middle meridi- 
onal fibres — that is, of all those fibres which hinder the advancement of the 
lens and diminish the size of the external zonula ring. If these fibres are not 
sufficient, the ciliary processes cannot hold back the lens by means of the 
anterior leaf of the zonule ; the lens pressed forward by the vitreous pressure, 
increased by each act of accommodation, pulls the ciliary process forward. 
The anterior surface of the ciliary body rotates round a fixed point in the 
region of Schlemm's canal. Through the medium of the external leaf of the 
zonule and the ciliary processes, the lens, pressing forward, pushes the root 
of the iris around against the ciliary body and the choroid. The excretory 
channels are closed, and the secondary increased tension begins. Schoen's 
conclusions are as follows: 1. All primary forms of glaucoma are due to ex- 
cessive strain of the accommodation. 2. The mode of action of this cause is 
a double one ; a strain on the sheath of the optic nerve and a pressing forward 
of the lens. The first leads to excavation, the second to increased tension. 
3. So long as the fibres of the ciliary muscle do their duty, the result is merely 
an accommodative excavation, or glaucoma simplex without increased tension. 
If, however, the inner fibres of the ciliary muscle are weak, the lens presses 
forward, and glaucoma, with increased tension, begins. 4. Both methods of 
action may occur together in various ways. An accommodative excavation 
may become a pressure excavation, as soon as the tension is abnormally in- 
creased. 5. The pathological changes seen in the ciliary muscle are but the 
consequence of the gradually developing inflammation, which has obscured 
the preliminary changes. In the first stage of glaucoma the only change would 
be a degeneration of the above-mentioned muscular fibres. 

Partial Embolism of the Inferior Division of the Central Eetinal 
Artery associated with repeated previous Attacks of Chorea. 

Benson, in Ophth. Review for January, 1886, reports the case of a house- 
painter, aged twenty-one, who, on the previous evening while reading, noticed 
the sight of the right eye rapidly fail, until within a few seconds he became 
totally blind in that eye. In about three minutes the sight began to clear 
from below upward, and gradually improved, till in about fifteen minutes the 
field of vision reached the horizontal line, where it ceased abruptly, and has 
since remained. The perimetric examination showed absolute loss of the 
upper half of the field. He had been subject to left hemichorea for some 

years. R. E. V.= with — D. 6, tension normal ; L. E. V. = — with 

nviii VI 

— D. 7, tension normal. Upper half of disk normal, with myopic crescent and 
deep physiological cupping. Lower half of disk hazy and whitish ; lower half of 
retina cedematous, and whitish-gray in color. The macula showed the typical 
" cherry-red spot," surrounded by a distinct halo. Upper half of retina ex- 
hibited the "shot silk" appearance. There were no attenuated or empty 
vessels, and no hemorrhages. There was total loss of light-sensation in the 
lower half of the retina. The retinal oedema disappeared in a few days. One 

NO. CLXXXIIT. — JULY, 1886. 16 



242 PROGKESS OF MEDICAL SCIENCE. 

small flame-shaped hemorrhage appeared at the lower outer margin of disk, 
but it was soon absorbed. The vessels began to diminish in size and to show 
the appearances of thickened coats. In about a month the vessels were 
markedly diminished in size, and a number of bright yellow spots, which had 
appeared near the macule, were absorbed. Vision remained unchanged. 

In this case the sudden and total blindness of one eye, followed by the re- 
covery in a few minutes of half the field of vision, and permanent loss of the 
other half, would seem to imply that the embolus, in the first instance, blocked 
the central artery at or before its bifurcation, and was dislodged from that 
situation, and washed into the inferior division of the vessel before any per- 
manent injury was done to the retina. The early reestablishment of the cir- 
culation in the lower half of the retina, without the restoration of vision, and 
the subsequent contraction of the vessels and atrophy of the retina, may be 
explained by assuming that an embolus of irregular shape only partially filled 
the lumen of the branch into which it drifted. The spasmodic contraction of 
the arteries, aided by the intraocular pressure, were at first sufficient to com- 
plete the arrest of the circulation produced by the partial embolus ; but the 
spasm passing off in a few minutes, permitted the blood to flow slowly through 
the vessels, which were thus again filled, but at a lower tension than the nor- 
mal. This patient had had an attack of acute rheumatic fever, and had 
suffered from left hemichorea, but there was no cardiac lesion demonstrated. 

On Changes in the Fundus of the Eye in Sepsis. 

Boyer (Arch, of Ophthal., xv. 1) gives the results of his examinations of 
eyes of women suffering from puerperal fever and of lying-in women not sep- 
tically diseased, as follows: 1. Ketinitis septica, composed of hemorrhages 
and the so-called Roth spots, is only pathognomonic of sepsis, where all other 
diseased conditions which may give rise to similar changes are eliminated. In 
typhus this affection of the eye has never been observed. It appears as well 
in the phlebitic as in the lymphangitic form of puerperal fever. 2. In ordi- 
nary panophthalmitis there is always suppurative choroiditis, although it 
may not originate in the choroid. He distinguishes between (1 ) suppurative 
choroiditis, which, if not traumatic, proves the existence of a septic disease, 
and in many cases ulcerative endocarditis; and (2) suppurative retinitis, 
which affects the choroid secondarily, and thus leads to the ordinary pan- 
ophthalmitis. It begins as an embolic inflammation of the retina, leads to 
suppuration of the latter, and involves the vitreous and choroid. It always 
means sepsis, and usually ulcerative endocarditis. 

Epilepsy with Optic Neuritis, Cured by Enucleation of the 
Wounded Eye. 

Galezowski, in Recueil d' Ophthal. for January, 1886, reports a case of this 
nature occurring in a gentleman, aged forty, who had lost the right eye by the 
explosion of a shell six years before. The anterior portion of the globe had 
been excised. The stump was still very sensitive. In May, 1883, the patient 
had the first epileptiform attack, and in the course of two months he had six 
attacks. Since then the vision in the left eye has steadily failed. In October, 

1883, when Galezowski first saw him, vision was reduced to — , and there was 

XV 



OPHTHALMOLOGY. 243 

marked neuroretinitis. The painful stump was at once enucleated, and was 
found to be cartilaginous in consistence. The choroid was disorganized, and 
contained numerous bone-cells. The optic nerve-fibres were atrophied and 
surrounded by enormously hypertrophied connective tissue. From the time 
of the operation the epileptic attacks ceased, and the vision in the left eye 
began to improve, and in April, 1884, he could read Snellen No. IV. with 
+ D. 6. He regards the case as one of reflex sympathetic action, which pro- 
duced the neuroretinitis and the cerebral trouble. There was produced some- 
where in the cerebral substance, either in the crura or optic thalami, a lesion 
analogous to what the ophthalmoscope showed in the optic disk of the left eye. 

Acute Eheumatic Retrobulbar Neuritis. 

Perlia (XI. mon.fiir Augenheilk., April, 1886) reports an interesting case 

occurring in a man, aged twenty-eight. After long-continued exposure to 

cold and wet, the patient, who was an engine-driver, complained of indistinct 

vision and great pain in the right eye. There were photophobia and lachry- 

mation, and pressure of the eye backward was painful. All movements of 

20 
the eyeball caused pain. V. = — . The field was concentrically limited, 

especially upward. Ophthalmoscopically nothing abnormal. Two weeks 

later there was marked improvement in all the symptoms. A few days later 

the same symptoms developed in the left eye, but in a much more intense 

20 
degree, vision being reduced to — and the field narrowed to a minimum, 

but no ophthalmoscopic evidence of any trouble. In both instances the 
patient was kept in the dark, and the ungt. ciner. was rubbed on the temples 
twice a day, and mercurial inunction every three hours, according to indica- 
tions. The result was a perfect restoration of vision and of the visual fields. 
Perlia regards the case as one of rheumatic inflammation of the sheath of the 
optic nerve, which extended to the interstitial connective tissue of the nerve, 
and produced paralysis of the nerve fibres by pressure from the exudation. 

The Insufficiency of the Power of Convergence. 

Landolt's paper is somewhat technical, but his large experience gives it 
real value (Bericht der 17 ten Versammlung der Ophthal. Ges., 1885). So long 
as the convergence is positive it may be directly determined by Landolt's 
ophthalmodynamometer. If it is negative, it may be determined by the 
strongest abducting prism, which may be overcome in or by distant vision. 
The amplitude of convergence is represented by the difference between the 
maximum and minimum of convergence. If it is desirable to know whether 
the power of convergence of a patient is sufficient or insufficient, and whether 
any asthenopic symptoms are due to insufficiency of this function, we must 
start from the maximum of convergence in our elucidation of the question, 
and we must also know just how much convergence the patient needs for his 
work. For prolonged work a surplus of convergence is necessary, in order 
to replace the power lost during the work. It is not until we know this 
" reserve fund " that we can with certainty say in any given case that insufi- 
ciency of convergence, of so many meter-angles, is present. This reserve 



244 PROGRESS OF MEDICAL SCIENCE. 

force cannot, of course, be an absolute quantity, the same for all cases, but 
there must be a certain constant relation between the prolonged work and 
the necessary reserve force, or asthenopia will result. 

Experience teaches us that as soon as the amount of insufficiency becomes 
greater than 1.5 meter-angles, it will be impossible to help the patient by 
prismatic glasses, for 1.5 meter-angles of convergence correspond to about 
a prism of five and a half degrees before each eye, which will be found too 
strong to be worn with any comfort. In such a case we must think of 
tenotomy of the external recti, or advancement of the internal recti, or of a 
union of both. Experience has also taught us that there are two kinds of 
muscular or motor asthenopia, a peripheral and a central kind. The first is 
the typical asthenopia muscularis, dependent upon the absolute or relative 
power of the adductors and upon their insertion. The central form of 
asthenopia has its cause in the sensorium, and depends upon a disturbance in 
the innervation of the converging muscles, and in many cases of the power 
of fusion. Landolt is of the opinion that these two forms of motor asthen- 
opia are frequently characterized by the amplitude of the convergence. In 
cases of simple overbalance of the abductors, without alteration of the 
muscles and without disturbance of innervation, tenotomy of one or both 
external recti gives excellent results. Equally favorable results are gained 
by tenotomy in cases of absolute diminution of the amplitude of convergence 
with marked increase of the negative portion, though advancement of the 
internus generally acts better. In cases where there is diminution of the 
positive convergence but no increase of the negative portion, tenotomy of 
the externi is indicated. If, however, the minimum of convergence is only 
weak, advancement of the interni is preferable. 

If both components of the amplitude of convergence are perceptibly 
diminished, the second or neuropathic form of insufficiency is usually present. 
Similar conditions are met with in cases of excessive myopia, where, in con- 
sequence of elongation of the eyeball, the muscles are extremely stretched and 
have lost in elasticity, and where the divergent position of the eyes is a still 
greater obstacle to the action of the interni. The amplitude of convergence 
may here be reduced to three meter-angles without any considerable increase 
in the minimum of convergence. In such cases no operative procedure gives 
satisfactory results, for instead of increasing the amplitude of convergence, 
all operations will be found to diminish it still more. Prisms are not to be 
thought of, and even advancement produces but a transient effect. 

Landolt also states that even in normal absolute amplitude of converg- 
ence and power of accommodation, the relative power or amplitude of these 
functions may be insufficient. This condition of things is usually met with 
in young hypermetropes. Operative interference should never be allowed 
in these cases. He considers it better to regard these cases as examples of 
excess of relative positive range of accommodation or spasm of accommoda- 
tion, and to treat them as such. 

The more Modern Operations for Trichiasis. 

Benson's paper is a practical one [Royal London Ophthal. Hosp. Rep., xi. 1). 
In partial trichiasis he advises electrolysis with a Leclanche battery, using 
ten cells. A fine electrolysis needle is attached to the negative pole, and a 



OPHTHALMOLOGY. 245 

large pad to the positive pole. The needle is then passed along the hair to 
be destroyed nntil its point reaches quite to the extremity of the bulb ; con- 
tact is then made and the circuit completed by applying the pad to the 
temple or eyebrow. The electrolytic action of the current decomposing the 
watery elements of the tissues, produces a bubbling of hydrogen gas around 
the needle, and a slough forms in a few seconds. When the ring formed 
round the cilium and needle is of sufficient size to insure the destruction of 
the bulb, the needle is removed and the hair caught by a pair of forceps and 
drawn out. If it does not at once come out and bring with it a mass of 
grayish gelatinous slough, it is better to reapply the needle, for unless the bulb 
is fully destroyed the hair may grow again. Each hair must be so treated, 
unless two or more grow so closely together that they can be simultaneously 
destroyed. The advantages of this method of treatment are as follows : 
1. We can destroy with certainty and without any disfigurement of the lid, 
any number of individual aberrant cilia. 2. There is no need for hurry in 
applying the needle, as no action takes place until the second pole is placed 
in contact with the skin. 3. The effect can be gauged with perfect accuracy. 
The cilia which cause trouble in trichiasis are not the normal hairs in an 
abnormal position, but are generally newborn hairs produced by the hyperaemic 
condition of the original bulb, which cause the latter to send off buds which 
develop fresh hairs. 

Nerve-stretching — Badal's Operation. 

Lagrange's paper [Archives d' OphthaL, Jan., Feb., 1886) is a discussion of 
the advantages of Badal's method of stretching the external nasal nerve in 
the treatment of a large number of grave lesions of the eye. He considers 
that the laceration and rupture of a sensitive nerve possess great advantages 
over a simple stretching, and are without any unpleasant consequences, and this 
is especially true of the external nasal nerve. It is particularly efficacious in 
relieving the element of pain, when the latter predominates over all the other 
symptoms. In chronic lesions of the eye, where there is but little pain, but 
where the anatomical changes are extensive, the result is on the contrary 
either trifling or nil. In performing the operation, it should be remembered 
that in most cases the bifurcation of the external nasal nerve occurs within the 
orbit in front of the pulley of the superior oblique muscle. 

Badal's directions for the operation are as follows : Place the index finger 
on the eyeball immediately over the superior orbital margin, the palmar sur- 
face forward and the end of the finger resting against the side of the nose. 
The point of exit of the nerve is found exactly at the middle of the finger- 
nail. A short curved incision is then made, corresponding to the internal and 
superior orbital margin, reaching from the internal angle to the pulley of the 
superior oblique, and about two cm. long. The muscular fibres are then divided, 
which exposes the nerve with its accompanying artery and vein. A strabis- 
mus hook is then passed beneath all three, and elevates them from the peri- 
osteum ; and on the hook the nervous filaments are isolated and stretched till 
they are ruptured. The wound is then closed antiseptically. The dangers 
are suppuration and diffuse phlegmonous inflammation, or the formation of 
cicatricial bands, which sometimes resemble a veritable cheloid formation. 



246 PKOGKESS OF MEDICAL SCIENCE. 

Paralysis of the Motor Nerves of the Eye, and their Treatment 

BY THE BrOMOHYDRATE OF PELLETIERINE. 

Galezowski here records his results in the use of a decoction of the bark 
of the pomegranate in the treatment of oculomotor paralyses (Eecueil cV Ophthal., 
March, 1886). He had observed that those patients, who had been taking a 
decoction of pomegranate bark for the relief of taenia, complained of vertigo 
and amblyopia, and sometimes of diplopia, and in one of them he had demon- 
strated a certain degree of spasm in the ocular muscles, which lasted more 
than an hour. He therefore ordered prepared the bromohydrate of pelle- 
tieriene, in the form of a syrupy mass containing crystals, readily soluble in 
water. He prescribed this in the form of a syrup, of the strength of 1 gramme 
to 120 grammes, of which four teaspoonfuls Avere to be taken daily. He records 
seven cases of amelioration or cure under this treatment. He recalls the ex- 
periments of Dujardin-Beaumetz, who injected in man the sulphate of pelle- 
tierine in doses of 50 grammes and produced vertigo, contraction of the pupil, 
cloudy vision, and marked engorgement of the retinal vessels, with paresis 
of the lower extremities. Galezowski has not observed that the drug exerts 
any curative action on paralysis of the ciliary muscle. 

Eesearches and Remarks upon Ocular Grafting or 
Transplantation. 
Terrier [Archives d' Ophthal., Jan., Feb., 1886) gives a resume of the five 
cases hitherto published, in which attempts have been made to transplant an 
animal's eye to the empty orbit of the human species. In four of these cases, 
the eye of the rabbit was employed, and in one case, a dog's eye. The patients 
varied from seventeen to sixty-six years of age, and the one case which suc- 
ceeded occurred in a robust man of thirty-five years. In the four unsuccessful 
cases, the grafts failed on the fourteenth, third, sixth, and nineteenth days 
after the operation. Terrier thinks that Chibert's "suture en bourse" is bad 
and ineffective, because the suture which passes through the conjunctiva soon 
causes ulceration of the cornea. He also disapproves of Chibert's plan of re- 
moving all the cellular tissue covering the sclerotic, because it diminishes the 
chances of cellulo-vascular adhesion. He regards Bradford's method as much 
superior to the others, viz., the suturing of the optic nerve, that of the straight 
muscles to the subconjunctival cellular tissue, and finally that of the con- 
junctiva. He also approves of the iodoform dressings of Bradford, and 
especially the prolonged occlusion of the eye. 

The Infecting Germs Contained in Lachrymal Sac Abscesses, 
and their relation to antiseptics. 
Sattler's article is one of great importance (Bericht der llten Versamm- 
lung der Ophthal. Ges., 1885). The only way to recognize the various kinds 
of microorganisms contained in pus from a lachrymal sac is to isolate them by 
culture, and as culture-ground the best is what he calls " Fleischwasserpep- 
tonagaragar," which seems untranslatable. In twenty-eight specimens of pus 
from inflamed lachrymal sacs one variety of coccus was found in eighty-three 
per cent, of the specimens of the ordinary pus fungus, discovered by Ogston, and 
first described by Rosenbach : the staphylococcus pyogenes in its three varieties, 



OPHTHALMOLOGY. 247 

albus, aureus, and cytreus. Sattler also found two other cocci-like microbes ; 
one resembling the pneumonia-coccus of Friedlander, and forming moist, 
grayish, nail-like masses. The other kind grows on gelatine in yellowish- 
white, elevated masses, with thickened minute edges and wax-like surface, 
hence the name of micrococcus cereus. These cultures consist of round or 
oval elements, with sometimes roll-like or 8-shaped or rod-like structures in 
their midst. 

Sattler found six varieties of rod-bacteria, only one of which developed real 
spores of an oval form and strongly refracting qualities. One variety possessed 
the power of rapidly liquefying the gelatine. Another variety showed a rapid, 
diffuse growth on agar-agar, but grew very slowly on gelatine. Its cultures 
consisted of short, very active rods with rounded ends. Another variety con- 
sisted of similar thick rounded rods, but destitute of any motion. Another 
variety consisted of short, slender, movable rods, extending rapidly over the 
surface of the agar-agar in the form of peculiar fusiform or belt-like, or stel- 
late figures with three rays. The cultures of this variety grow very slowly 
on gelatine, and resemble the Meibomian glands. The sixth variety consists 
of rounded, slightly elevated, grayish, punctate masses, opaque by transmitted 
light. 

One important question to be decided is, whether all these varieties of mi- 
crococci are endowed with pathogenetic properties, or whether some of them 
are innocuous. To solve this question, an incision was made in the cornea of 
animals and a small portion of the pure culture of each variety was intro- 
duced into the wound. The most intense suppuration was always caused by 
the staphylococcus pyogenes, accompanied by hypopyon and iritis. The variety 
resembling the pneumonia-coccus and the micrococcus cereus also produced 
suppuration with hypopyon, but not so violent as that caused by the first 
variety. Among the bacillar-cocci, that variety which resembled the bacteria 
of putrefaction produced intense hypopyon-keratitis. The other varieties of 
bacillar-cocci also produced suppuration, but of a much less intense type. 

In regard to the antiseptic properties of the iodide of mercury, Sattler dif- 
fers decidedly from Panas. A saturated solution of this salt (1 : 25,000) is not 
antiseptic. But it is much more soluble in chloride of mercury solutions, and 
very readily in potassium iodide solutions. If we dissolve 0.1 gramme of iodide 
of mercury in 1000 cubic centimetres of a 0.2 per cent, solution of mercuric 
perchloride, we get a solution which has a greater antiseptic power than the 
simple 0.2 per cent, of sublimate solution, and is almost non-irritating to the 
conjunctiva. If we replace the iodide of mercury by the chloride of mercury, 
or, in other words, use a 0.3 per cent, sublimate solution, instead of a 0.2 per 
cent, sublimate solution, we do not get the same effect that we do from the 
mixed solutions of HgCl 2 -(-HgI 2 . 

The Antiseptic Action of Cocaine, Corrosive Sublimate, and Chlo- 
rine Water upon the Secretions in Dacryocystitis, Tested by 
Inoculations of the Cornea. 

Schmidt-Bjmpler's paper is purely experimental {Arch, of OphthaL, xiv. 4). 
His inoculations numbered forty-four, and in all he made a note of the length 
of time the secretions remained in contact with the disinfecting substances. 
The muriate as well as the salicylate of cocaine was used in solutions of 



248 PROGRESS OF MEDICAL SCIENCE. 

four per cent., but there was uo perceptible difference in the action of the two 
preparations. The secretions coagulated in them into small balls. Their 
infectious nature remained unimpaired after lying in the cocaine solution for 
from one to three minutes, and after ten minutes they still produced well- 
marked septic inflammation, though somewhat mitigated in character. Im- 
mersion of three minutes' duration in a solution of corrosive sublimate of the 
strength of 1 to 3000 was usually not sufficient for the complete destruction 
of the infectious properties of the matter, from five to ten minutes being 
usually required. Schmidt-Eimpler regards chlorine water as superior to the 
sublimate in quickness of action as a disinfectant. The chlorine water of the 
German Pharmacopoeia is well borne by the eye. Even spores of the anthrax 
bacillus, which are endowed with an exceptional power of resistance, become 
disinfected within three hours, if treated with moist air containing 0.32 to 0.18 
per cent, of its volume of chlorine gas. He therefore recommends chlorine 
water as the best disinfecting substance for the eye. 

Experiments on the Action of Bacteria in Operations on 

the Eye. 

Knapp gives the results of a series of experiments on rabbits, instituted for 
the purpose of ascertaining how a pure wound differed in its healing process 
from an infected wound {Arch, of Ophthal., xv. 1). He first made a pure opera- 
tion on one eye, using, however, no chemical agents; but operating on a clean, 
healthy eye with clean hands and instruments — that is, aseptically — and, after 
the operation, leaving the eye alone without a bandage. The other eye was 
operated upon in the same way, consequently subjected to exactly the same 
traumatism, but inoculated in one or another way with a pure culture of bacteria. 
All the eyes operated upon aseptically recovered, but almost all of those 
infected with the microbes were lost by suppuration ; only those recovered in 
which the operations had been superficial and limited. The pyogenous 
microbes employed for the purpose were the staphylococcus pyogenes aureus, 
albus, and citreus, the bacillus pyogenes fcetidus, and the micrococcus of 
osteomyelitis. He also inoculated several eyes with a fermentation fungus, 
that of pink yeast. This microbe produced parenchymatous inflammation, 
but no suppuration, and hence is not pyogenic. Knapp concludes that his 
experiments, without an exception, have sustained the theory of the bacterio- 
logical influence on the formation of pus. 

Skiascopy; its Advantages and its Place in Ophthalmology. 

Chibret {Arch, de Ophthal., March- April, 1886) proposes to employ the 
term '' skiascopy," in place of the terms keratoscopy, retinoscopy, pupillo- 
scopy, and phantoscopy, which have been hitherto employed to designate this 
method of examination of the refraction of an eye ; a method of determining the 
ocular refraction based upon the examination of the shadows which are formed 
in the eye when light is thrown into it. This method, he considers, has some 
advantages : it does not require a refraction ophthalmoscope, but simply a 
plane mirror; its determinations are independent of the static or dynamical 
refraction of the observer; it gives an approximate idea of the refraction 
much more rapidly than the examination with the upright image ; it may be 



OTOLOGY. 24:9 

employed with turbulent children, and in cases of nystagmus. If the shadow 
moves in the opposite direction to that of the mirror, and the pupil immovable, 
the eye is myopic. If the shadow moves in the same direction as the mirror, 
the patient is hypermetropic two dioptrics or over. 



OTOLOGY 



UNDER THE CHARGE OF 

CHARLES H. BURNETT, M.D., 

PROFESSOR OF OTOLOGY IN THE PHILADELPHIA POLYCLINIC AND COLLEGE FOR GRADUATES IN MEDICINE, ETC. 



Membranous Closure of the External Auditory Canal. 

Herman Rothholtz, of Gleinitz, relates the following case {Arch. f. 
Ohrenh., Bd. xxiii. p. 183). In a woman, twenty-one years old, who had suf- 
fered from otorrhoea until her fifteenth year, there was found on the right 
side, three millimetres in front of the membrana tympani, a flat, pseudo 
membrana, of tendinous appearance, which entirely closed the auditory canal 
This diaphragm was incised by several radial cuts and a cotton tampon placed 
in the opening, and in a short time the false membrane disappeared. The 
hearing became considerably better, and the subjective noises, previously 
annoying, ceased. In three months no tendency to reappear had shown 
itself. In the much thickened membrana tympani two perforations were 
detected. 

Foreign Bodies in the Ear. 

Hedinger, of Stuttgart (Arch./. Ohrenh., Bd. 23, p. 184), reports 133 cases 
of foreign bodies in the ear, in a total of 12,225 aural patients. The cases 
offered, as a rule, the ordinary mineral, vegetable, and animal substances 
which get into the ear. Among the rare occurrences are mentioned : a worm ; 
a collection of beeswax, said to have been poured into the ear, while soft, by 
a physician, for the cure of tinnitus aurium; an incisor and a molar tooth. 
The length of time these objects had been in the ear varied from a few hours 
to fifteen years. Whenever any symptoms were present they consisted in 
deafness of varying degrees, pain, sense of pressure and tightness, and sub- 
jective noises. The reflex phenomena consisted in headache and toothache, 
dizziness, reeling, coughing, and vomiting. Epilepsy or similar severe neu- 
roses were not observed in any instance. Examination revealed either no 
local changes, or there were detected swelling, bleeding, and inflammation in 
the external auditory canal. Several times perforation of the membrana 
tympani ensued, either as a result of the pressure of the foreign body or of the 
suppurative process induced by it. In these cases the same observation was 
made as has been made in other cases of foreign body in the ear, that the 
lesions in the ear are due to unskilful endeavors at extraction, rather than to 
the simple presence of the foreign substance in the ear. 



250 PKOGRESS OF MEDICAL SCIENCE. 

Removal of the foreign body was effected eighty-eight times by simple 
syringing, the posterior wall of the auditory canal being placed downward. 
Substances likely to swell may be syringed out with oil, instead of water. 
Instillations of glycerine may be used to contract a swollen substance when- 
ever the removal cannot be speedily accomplished on account of great swell- 
ing, and whenever there is no danger in delay, for this method is a slow 
one. In some instances when a foreign substance lay behind the mem- 
brana, it was pushed through the perforation by a forcible inflation from the 
air-bag. Thirty-four times the author employed instruments for the removal 
of the foreign substance, most frequently the instrument used being delicate 
forceps. In one instance a piece of cork, wedged in the auditory canal, was 
removed by charring with the galvanocautery. 

Morbid Changes in the Bone in the Auditory Canal of Ancient 

Peruvian Skulls. 

R. Virchow (Arch./. Ohrenh., Bd. xxiii. p. 170), in considering this sub- 
ject, makes first an analysis of the writings of Seligmann, Flower, B. Davis, 
and Welcker, upon exostoses in the auditory canal, and opposes the hypothesis 
of Seligmann, that exostoses in this position are due to the custom of slitting 
the lobule and widening it, common among the ancient Peruvians. The 
author examined one hundred and thirty-four skulls from Ancona, eighteen 
of which (three females) showed exostoses in the auditory canal. The most 
deformed skulls, however, had normal auditory canals. The exostoses in 
these cases occupy chiefly the outer half of the auditory canal, Yirchow hav- 
ing never seen them in the inner portion of the canal. The point of origin 
of the tumor is invariably from one of the edges (usually the posterior) of the 
pars tympanica of the temporal bone, which often, in the Peruvians, is incom- 
pletely united to the neighboring bone. The surface of the tumor is some- 
times smooth, often rough, corrugated, and indented. Sometimes several 
exostoses occur in close proximity to one another. The author describes the 
exostoses "as excessive growth (of bone) at points undergoing ossification," 
since they occur at that point where the cartilaginous part of the auditory 
canal unites with the osseous portion. 

Fracture of the Handle of the Malleus by a Blow on the Ear. 

Dr. A. Eitelberg, of Vienna ( Wiener rned. Presse, No. 43, 1885), gives an 
account of the rare occurrence of fracture of the handle of the malleus, as fol- 
lows : The patient, thirty-eight years old, was said to have received a blow, of 
relatively slight force, upon the ear, and soon afterward perceived a tinnitus, 
and whenever the nose was blown, a feeling of warm vapor streaming from 
the affected ear. Examination revealed only a slight dulness in the mem- 
brana tympani, and injected vessels on the manubrium mallei, with redness 
of the broad end at the umbo, the latter being separated from the other parts 
and pushed forward and downward. From the latter point a fold of the 
membrane extended to the periphery. Beneath the end of the hammer there 
was a small perforation with swollen edges. At the second examination, the 
broken end of the malleus had united with the rest of the handle, the latter 
appearing thickened and red, but otherwise normal. The fold had disap- 



OTOLOGY. 251 

peared, and the edges of the perforation were less swollen. When the author, 
three weeks later, saw the patient for the last time, the lower third of the 
manubrium appeared pale, and the point of fracture was indicated only by 
pale red transverse lines. The perforation appeared to be moving toward the 
anterior inferior periphery of the membrana. Suppuration occurred at no 
time. 

Abscess of the Brain caused by Otorrhcea ; Cured by an Operation. 

This case occurred in the practice of Schede, of Hamburg, and is reported 
by C. Truckenbrod, of Hamburg, in the Archiv f. Ohrenheilkunde, Bd. 23, pp. 
188, 189. A young man, twenty-eight years old, suffering from chronic puru- 
lent otitis media, was attacked by chill and then fever, with pain in the vertex 
and occiput. 

Upon the strength of these symptoms the mastoid foramen was opened by 
Schede, and thick, fetid pus was removed. At first, the symptoms improved, 
but soon the temperature rose to 39.6° C, and then ensued facial paralysis, 
loss of memory, and aphasic phenomena, and locally the fetor of the discharge 
increased and oedema set in about the ear. 

Cerebral abscess was diagnosed, and an operation undertaken for its relief. 
For this purpose, the incision over the mastoid was lengthened upward and 
backward about eight centimetres. After the galea was dissected back, there 
was detected, about three centimetres above and behind the auditory meatus, 
a small plug of pus projecting from a small fistula in the bone. Here the 
bone was chiselled away, but probing the exposed and granulating dura mater 
did not reveal the presence of pus. Nevertheless, extremely offensive cheesy 
flakes of pus continuously escaped from between the dura and the bone. 
Therefore, the cut was extended five centimetres further downward and 
behind, and the thin bone chiselled away, and by incising the dura mater a 
cupful of pus escaped from a cerebral abscess about the size of a small orange. 
This cavity was injected by a ^^th solution of corrosive sublimate, and 
drainage kept up. The result was very favorable, as the fever ceased and 
the general condition of the patient improved. The cerebral disturbances 
very gradually grew less severe. Subsequently upon two occasions the patient 
grew worse on account of a reaccumulation of pus in the abscess-cavity. 
Eighteen weeks after the first operation, the patient was discharged as cured. 
Yet at times he was at a loss for a word in writing or in describing external 
objects. 

The Eelation of the Chorda Tympani to the Perception of 
Taste in the Anterior Two-thirds of the Tongue. 

Dr. Edward Schulte, of Berlin {Archives of Otology, vol. xv. p. 62), 
having had an opportunity of observing an instance of accidental division of 
the chorda tympani, which was followed by paralysis of taste on the same 
side, has endeavored to investigate anew " the origin of the fibres of taste of 
the anterior two-thirds of the tongue." 

The case referred to was that of a lady, thirty-four years old, who had suf- 
fered from left otorrhoea and defective hearing since early childhood. A large 
polypus was at last found and removed by the snare. Eepeated cauterization 



252 PROGRESS OF MEDICAL SCIENCE. 

of the stump of the polypus having failed to destroy it entirely, an attempt 
was made to destroy the remnants by a sharp spoon. The procedure was 
efficient in the destruction of the polypus, but at the same time the chorda 
tympani was severed. Immediately the patient " experienced on the left side 
of her tongue a sensation as if a membrane were stretched over it," and at the 
first meal of which she partook, after her return home, she could not taste 
any of the food on the left side. The latter appeared to her as if burned, 
while taste on the right side was normal. When Dr. Schulte examined the 
patient eight weeks later, " there was no taste for bitter, sweet, acid, or saline 
substances on the left side, from the tip of the tongue back to the point where 
the circumvallate papilla? commence." Nor did the same substances, when 
applied within the limits named to the lateral border of the tongue, produce 
an impression of taste at any point ; while in the posterior third of the tongue, 
and from the median line to the right, all the statements as to the taste of the 
substances were prompt and exact. On the application of thermic irritants, 
such as ice, cold, warm and lukewarm water to the region devoid of the sense 
of taste, the statements were correct as regards the differences of temperature 
perceived ; but the patient was unable to decide whether the cold or heat 
emanated from a solid or a liquid substance. On applying a small pellet of 
ice, she felt a more intense cold than from a drop of cold water, but she was 
unable to say which of the two bodies was solid and which was liquid. The 
localization of tactile perceptions, tested with the sesthesiometer, shows no 
noticeable differences between the anterior part of the left half and the same 
part of the normal right half of the tongue. The perception of pain within 
the region devoid of taste was unchanged. 

The membrana tympani was, on the whole, devoid of defects, excepting a 
small segment, below and anterior to the short process of the malleus, which, 
with the flaccid membrane, was destroyed. The head of the malleus was 
plainly visible on account of the destruction of the flaccid membrane. 

It is maintained that this case demonstrates as clearly as an experiment on 
a living human subject, "that a severance of all the jDarts of conduction of 
the chorda is followed by a complete abolition of taste in the anterior two- 
thirds of the corresponding side of the tongue." 

The writer accepts the demonstration of Sapolini 1 as to the existence of a 
separate thirteenth nerve, of which the so-called chorda tympani is only the 
peripheral end. In view of this fact he holds that we can no longer speak of 
a function of the chorda, but that we are forced to assign the duty of supplying 
gustatory fibres to the anterior two-thirds of the tongue, to the nerve-trunk, 
called by Sapolini the thirteenth nerve, of which the chorda is simply the 
termination, while the glosso-pharyngeus innervates only the posterior region 
of the tongue with fibres of taste. 

BUPTURE OF BOTH MEMBRANE TyMPANORUM, AND CONCUSSION OF 

both Labyrinths. 

Dr. Keeler, of Cologne (Monatssch. f. Ohrenh., No. 6, 1885), gives an ac- 
count of the above-named injury to the ears, as follows: The lesion was pro- 
duced by an explosion, the membranse being ruptured close in front of the 

1 Fn tredicesimo nervo craniale, pp. 19. Milan, 1881. 



LAKYNGOLOGY. 253 

manubrium, which healed on the right side without suppuration, but on the 
left side, on account of simultaneous burning, the perforation healed after sup- 
puration. The effect of the explosion extended to both labyrinths, with 
greatest intensity on the left side, which was turned toward the source of 
explosion. It is rather remarkable that the usual symptoms, as hardness of 
hearing, vertigo, and tinnitus aurium were less marked at first than subse- 
quently, when in addition to these there were various cerebral symptoms, as 
insomnia, headache, muscse volitantes, irritability of temper, etc. There was 
no fever, yet the face was very red, and the pulsation of the arteries was very 
marked. The pupils were normal. In the course of eight months the brain 
symptoms were not entirely gone. The hearing on the left side was 0, and 
very much reduced on the right side. Tinnitus very great in both ears, with 
slight dizziness. It was supposed that a hemorrhage in the labyrinth, with 
consecutive inflammation had arisen, to which had been subsequently added 
hyperemia of the brain. 

Exfoliation of a Necrotic Cochlea, Containing the two Upper 
Whorls; Healing of the Suppuration, with only Partial Loss 
of Hearing in the Affected Ear. 

Dr. Joseph Gruber (Monatssch. /. Ohrenh., No. 8, 1885) relates the above- 
named case. The condition of the hearing was the interesting feature in this 
instance. Notwithstanding the profound nature of the lesion, a watch was 
heard in the affected ear, the left, when placed on the cheek-bone, and also 
upon the mastoid process. The tuning-fork placed upon the left frontal pro- 
tuberance was heard in the right ear, but from the left cheek-bone and left 
mastoid it was heard constantly in the left ear. When vibrating tuning-forks 
were held before the left auditory canal, they were heard by the patient cor- 
rectly. Further, the patient stated most clearly, that when the tuning-fork 
was placed on the finger which was pressed into the left meatus, the sound of 
the fork was heard plainly in the left ear. Moderately loud words were heard 
in the left ear, the right ear being firmly stopped, and words whispered 
through the speaking-tube into the left ear were distinctly heard by it. This 
condition of the ear, after such a lesion, corresponds to some extent with those 
of Cassells, Christianeck, and Jacobson. It is claimed by Gruber that the 
present theory of the part exercised by the labyrinth in hearing is considerably 
shaken by such cases. But it must be borne in mind that partial affections of 
the labyrinth, even when they induce destruction of certain of its parts, which 
are considered essential to sound perception, do not necessarily lead to total 
deafness. 



DISEASES OF THE LARYNX AND CONTIGUOUS 
STRUCTURES. 



UNDER THE CHARGE OF 

J. SOLIS-COHEN, M.D., 

PROFESSOR OF DISEASES OF THE THROAT AND CHEST, PHILADELPHIA POLYCLINIC. 



Tuberculous Ulceration of the Mouth. 
Dr. E. Clifford Be ale has reported (British Medical Journal, March 20, 
1886, p. 550) the case of a stonemason, aged forty -two years, who had always 



254 PROGRESS OF MEDICAL SCIENCE. 

enjoyed fair health, with the exception of a chronic winter cough. Shortly 
after Christmas, 1885, he began to complain of sore throat and difficulty of 
swallowing, the pain being referred to the right side of the fauces. A slightly 
painful glandular swelling existed under the jaw on the same side. An irreg- 
ular rounded patch, of the size of a sixpence, with raised cord-like edges, and 
a finely granular surface, was found on the mucous membrane between the 
last molar tooth on the right side and the right anterior pillar of the fauces. 
This patch, although in close relation to the tooth, did not appear to have 
been in any way irritated by it. It bore all the characteristics of a partially 
healed tuberculous ulcer, as seen on other mucous surfaces. No evidence of 
tubercle or syphilis could be traced elsewhere in the patient, with the excep- 
tion of a few hard nodules under and in the skin in the front of the neck. 
These had existed for a long time without perceptible change. Two sisters 
had died of phthisis at nineteen and twenty-three years of age, respectively, 
but there were no symptoms or physical signs of the disease in the patient 
himself. 

In a subject of diabetic phthisis, under the care of the compiler, a similar 
ulceration surrounded the posterior inferior molar on the right side, and 
extended up into the palate. The finely granular surface of the ulcer, in 
its entire extent, an ovoidal ellipsis one inch in length by one-third at its 
broadest portion, with corded but not undermined edges, was clean as in 
tuberculous ulceration generally, save for occasional accumulations of food. 
The adjoining mucous membrane of the palate was raised by numerous con- 
tiguous minute elevations similar in their gross aspects to those of acute tuber- 
culosis of the mouth and pharynx; but there was no intense pain in swallow- 
ing, as in acute tuberculosis, nor could any bacilli of tuberculosis be detected 
on microscopic examination of debris removed by scraping from the bed of 
the ulcer. All topical treatment, including that by lactic acid, was unavailing, 
despite the healing of similar looking ulcerations in the larynx under insuffla- 
tions with iodoform. 

In another case, looking very similar, under the compiler's care, an ulcera- 
tion in a similar locality, associated with unimpressionable laryngeal ulcera- 
tion, and attended with intense pain in swallowing, exists in an undoubted 
case of tuberculosis pulmonum et laryngis. 

In view of these facts, attention must be directed to the differential diagnosis 
between ulcerations of the mouth in tuberculous phthisis and ulcerations in 
diabetic phthisis. Absence of pain and absence of bacilli may be regarded as 
the discriminative factors. 

Unusual Wound of the Soft Palate. 

One of M. Pasteur's hydrophobic patients, a child, treated and cured, had 
been bitten on the soft part of the palate {British Medical Journal, March 20, 
1886, p. 555). 

Cylindroma of the Soft Palate. 

Sir W. Mac Cormac has reported [British Medical Journal, March 20, 
1886, p. 546) a tumor the size of a tangerine orange, which sprang from the 
left side of the soft palate of a woman, thirty years of age. It was firm and 



LARYNGOLOGY. 255 

elastic. The glands at the angle of the jaw were enlarged. It was excised 
after preliminary tracheotomy. Free hemorrhage occurred during the oper- 
ation. Mr. Butlin considered the tumor a transformed round-celled sarcoma. 

Accessory Tonsil. 
Jurasz (Monatsschrift fur Ohrenheilkunde, etc., 1885, No. 12) reports an 
accessory tonsil in an anaemic female, set. thirty. It was the size of a hazel- 
nut, and attached by a broad pedicle to the side of the pharynx, beneath the 
orifice of the right Eustachian tube at the uppermost portion of the salpingo- 
pharyngeal fold. It was removed with the galvanocaustic snare. The 
operation gave no relief to a parsesthetic condition of the pharynx which had 
occasioned the rhinoscopic examination ; but this paresthesia — scratching in 
the throat and irritative cough — subsided under treatment for a concomitant 
uterine malady. 

Acute Tonsillitis and Eheumatism. 
The long-known but imperfectly appreciated rheumatic character of many 
cases of acute tonsillitis has lately attracted considerable attention, and the 
value of the salicylates in such cases may be duly emphasized. Among 
other interesting communications we would note those of Mr. Fox and Dr. 
Easby in the British Medical Journal, January 9, 1886. 

Pemphigus of the Pharynx. 

Pemphigus of the pharynx and uvula, as part of the manifestation of acute 
febrile pemphigus in a negress, has been reported by Dr. Charles E. 
Gooding in the Canada Medical and Surgical Journal, and an instance of 
pemphigus of the pharynx in a case of general pemphigus in a married 
female set. forty-two, has been noticed by Mr. Eales in the British Medical 
Journal, January 2, 1886. 

Cocaine to the Pharynx in Hydrophobia. 

Cocaine to the pharynx in a two per cent, solution very much mitigated 
the suffering temporarily in a case of hydrophobia ( Wien. med. Woch., 1885, 
No. 40 ; Centralbl. f. klin. Med., March 13, 1886 ; N. Y. Medical Journal, 
May 1, 1886, p. 508), but did not retard the fatal result. 

Mycosis of the Throat. 
Dr. Henri Guinier, of Cauterets, reports in the Revue mens, de laryngolo- 
gie, etc., April, 1886, p. 181, a case of mycosis of the tonsil, palatal folds, 
and the circumvallate papillae of the tongue. Treatment was not satisfactory, 
but the deposits disappeared subsequently under influences which improved 
the general health. The author considers the deposition of these cryptogams 
as a sign of physiological poverty. 

Aneurism of the Left Internal Carotid Artery in its Extreme 
Upper Portion Rupturing into the Pharynx. 

Prof. M. F. Coomes, of Louisville, reports (Journal of Materia Medica, 
March, 1886, p. 37, from Med. Herald) an instance of this rare lesion in a 



256 PEOGRESS OF MEDICAL SCIENCE. 

female subject, the patient dying quickly by a hemorrhage. The aneurismal 
sac was found wedged between the angle of the jaw and the cervical portion 
of the spinal column extending almost to the base of the skull. 

In a right-sided aneurism in the pharynx, in a male patient now under the 
compiler's care at the Philadelphia Polyclinic, it is proposed to ligate the 
common carotid, should the treatment by rest and large doses of potassium 
iodide not produce marked benefit. Curiously, another of these rare cases 
has presented in his private practice. The aneurism is left-sided, in a female 
sixty-five years of age, the subject of diabetes mellitus. These cases are liable 
to be mistaken for abscess or neoplasm. The pulsation in the lateral wall of 
the pharynx should excite a suspicion of aneurism of the internal carotid, or 
of the ascending pharyngeal artery. 

Lateral Pharyngotomy for Extirpation of Malignant Tumors in 
the Tonsillar Kegion. 

Prof. J. Mikulicz, of Cracow, describes {Deutsche med. Woch., 11 u. 18 
M'arz, 1886, S. 178) four cases upon which he operated, the modifications 
requisite to fulfil the special indications, and the after-treatment ; concluding 
with some remarks on the infrequency of carcinoma of the tonsil, and on the 
•course of the disease. 

Neuroses of the Pharynx. 

Dr. Th. Hering, of WarsaAV, narrates in the Revue mensuelle de laryngolo- 
gie, etc., April, 1886, p. 177, two cases of cough due to rugous thickening of 
the pharyngeal mucous membrane behind the posterior palatine folds, cured 
by cauterization, and one due to a reel and slightly hypertrophied tonsil 
cured by extirpation of the gland. The diagnosis was based on production 
of cough by touching these structures with the probe. He also narrates the 
•case of a college lad with similar cough, in whom intense pains in the neck 
were excited on touching the parts with the electric cautery, and in whom, 
after cauterization of several of the largest granulations, torticollis to the 
right was immediately produced, with painful contractions of the muscles of 
the neck. This condition lasted for nine days, and ceased with the fall of 
the eschars in the pharynx, and the cicatrization of the wounds. The cough 
diminished and lost its nervous character, but reappeared from time to time 
as a symptom of a concurrent bronchitis. The torticollis was hypothetically 
attributed to irritation of some nerve filament which escaped destruction in 
the cauterization, provoking a neuritis which, by its reflex action, was fol- 
lowed by serous infiltration of the group of muscles affected. 

Nervous cough from pharyngeal irritation is not infrequent. The compiler 
can recall, too, a number of instances of persistent irritative cough of several 
years' continuance, cured by electric cauterization of diseased tonsillar 
lacunae, in some instances detected only by drawing the tonsil forward and 
inward, so as to expose its posterior surface. Little papules, the size of pin- 
heads, supposed to be of neurotic origin, and situated upon the inner surface 
of the palatine folds, have likewise been found by the compiler to be causes 
of occasional irritative cough, which has ceased on their destruction. The 
indication is, in cases of cough that canno be accounted for by lesions of 



LARYNGOLOGY. 257 

ordinary occurrence, to examine carefully every portion of the surfaces of the 
pharynx and its contents which can be brought under direct or instrumental 
inspection. 

Stricture of the CEsophagus. 

Dr. B. Ward Bichardson, of London, in The Asclepiad, January 25, 1886, 
p. 65, urges the importance of using all food and drink cold, inasmuch as 
heated food tends to produce contraction of the circular muscular fibres of 
the oesophagus, while cold has a tendency to relax them. Heat irritates, 
cold acts as a sedative ; heat excites pain, cold soothes. Hence he advises 
using a cold tube instead of a warm one in attempts at dilating the stricture. 
It passes much more easily. He immerses the dilator for a few minutes in 
chilled butter as. the most ready lubricant. 

Sir Wm. Mac Cormac reports, in the Lancet, January 30, 1886, p. 191, a 
case of cicatricial stricture of the oesophagus treated by gradual, and after- 
ward by forcible dilatation. Wm. , set. twelve, swallowed liquor potassse, 

Aug. 13 ; progressive dysphagia, and emaciation ; gastrostomy considered ; 
nutrition by enemata. Sept. 29, urethral bougie No. 4 passed six inches 
from teeth ; stricture seemed less marked lower down ; bougie pushed into 
stomach. Patient swallowed milk. Dilatation with urethral and then with 
small oesophageal bougies, with gain of ten pounds in weight. 

Carcinoma of the CEsophagus. 

Dr. T. S. K. Morton, of Philadelphia {Semimonthly Journal of the Pro- 
ceedings of the Pathological Society of Philadelphia, January 26, 1886, p. 1), 
presented to the Society a specimen from a married female domestic, set. sixty- 
one, of scirrhus carcinoma of the lower third of the oesophagus, involving the 
neighboring retroperitoneal glands and, to a slight degree, the head of the 
pancreas, with numerous small metastastic nodules in the stomach and the 
liver, principally in the Spigelian lobe, and in no other organs. There was 
no dilatation of the oesophagus above the cancer. Complaint had begun but 
nine weeks before admission to the Pennsylvania Hospital, and the patient 
died twelve days after admission. 

A New Nasal Speculum. 
Dr. L. Katz, of Berlin, describes and pictures [Berliner Min. Woch., Marz 
1, 1886, S. 144) a new nasal speculum, consisting of a wire so bent as to enter 
both nostrils, with an extension to be attached to a headband. It is thus 
automatically self-supporting, and turns up the tip of the nose at the same 
time that it distends the alas. 

(ESOPHAGOTOMY. 

Mr. Bennett May reports, in the Lancet, January 13, 1886, a successful 
oesophagotomy in a child seven years of age, for removal of a halfpenny 
swallowed three years and a half before the operation. It had ulcerated into 
the right bronchus and was lying partially in both tubes. There is a slight 
constriction at the point of ulceration, but a bougie can be passed and food 
can be swallowed. 

NO. CLXXX1II. — JULY, 1886. 17 



258 PROGRESS OF MEDICAL SCIENCE. 

Dr. T. M. Markoe, of New York, reports, in the New York Medical Jour- 
nal, May 1, 1886, p. 481, two cases of oesophageal operation for removal of a 
foreign body, one of which saved the life of the patient, a man, twenty-four 
years of age; and he presents an admirable summary of the indications for 
the operation, and the preferable methods of procedure and after-management. 

Epistaxis 
Cure by antipyrin locally, 1 : 30 in water on lint, is reported by Dr. Lav- 
rand (Jburn. de med. et de chir. prat; London Medical Record, March 15, 1886). 

Coryza. 
Beneficial results from insufflations as follows : (1) Menthol, 2 parts ; roasted 
coffee, 50 parts ; white sugar, 50 parts. (2) Cocaine hydrochlorate, 1 part; 
roasted coffee, 50 parts ; white sugar, 50 parts ; are reported by Kabow 
{Deutsche med. Woch. ; New York Medical Journal, April 24, 1886, p. 480). 

Aluminium Acetico-tartaricum, and Aluminium Acetico-glyceri- 
natum slccum in laryngitis, pharyngitis, chronic rhinitis, 

AND Oz.ENA. 

Dr. Max Sceleffer, of Bremen, reports (Deutsche medicinische Woch- 
enschrift, November 23, 1885) some remarkable results from local applications 
of those salts to diseased mucous membrane of the upper respiratory tracts. 
The atrophic tissues acquire a fresher and more normal aspect ; and the odor 
from ozsena is overpowered more quickly than by any other treatment. He 
recommends it in all affections of the nose, pharynx, and larynx, attended 
with the formation of crusts or scabs, and he characterizes its action as caustic- 
astringent. The agent is applied in powder. In half a minute the part is 
white, as though cauterized. Great sense of dryness is produced, soon fol- 
lowed by intense serous secretion lasting for several hours. Then dryness re- 
turns within forty-eight hours, small sloughs fall off, sometimes with slight 
capillary hemorrhage. The secretions become more mucopurulent, and the 
crusts loosen with the sloughs. In from five to seven days the action of the 
remedy ceases ; the healthy mucous membrane has recovered its normal appear- 
ance, the diseased membrane has become paler, and is more tense upon the 
turbinate bodies. 

The acetotartrate of aluminium is also used as a wash or douche in the pro- 
portion of one teaspoonful of a fifty per cent, solution to from one-half to one 
litre of water. Ten drops of a twenty per cent, solution in 200 parts of luke- 
warm water, have been used with great effect as a wash and gargle, in chronic 
nasopharyngeal catarrh with profuse mucopurulent secretion and desiccation 
into crusts even when associated with pharyngitis sicca. 

The glycerated salt is five times as strong as the other. It has been used 
effectually in simple chronic rhinitis, laryngitis, and laryngeal phthisis. It 
is no more irritant than boric acid and much more effectual, especially in 
ulceration of the larynx. 

The writer had some acetotartrate of aluminium made for him in Philadel- 
phia, with which he has thus far failed to secure results as satisfactory as 
those claimed above. Awaiting a supply from Bremen, an expression of 



LARYNGOLOGY. 259 

opinion as to its efficacy must be held in reserve. The high repute of Dr. 
Schaffer leads to the inference that the writer has been working with a drug 
of inferior quality. 

Nasal Polypi. 
Mr. Spencer Watson, in the British Medical Journal, March 20, 1886, p. 
548, has devised a new lever forceps for the removal of nasal polypi and the 
redundant tissues in chronic rhinitis. He thinks that necrotic ethmoiditis 
(Woakes) exists in but few cases of polypi, if any, but that hypertrophy of 
the turbinate bodies is frequently associated therewith. 

Hay Fever and Allied Affections. 

The return of the hay fever season suggests a return to the subject. It 
may be conceded that certain individuals or groups of individuals inherit or 
acquire an idiosyncratic supersensitiveness of the conjunctival and nasal mu- 
cous membranes and their extensions, in some instances comprising the entire 
upper air-tracts and even the bronchi. The access of certain well-known 
dusts to the nasal or adjacent mucous membrane, and in neuromimetic in- 
stances, even the dread of the access of such dusts, excites a peculiar train of 
distressing morbid phenomena to which the general term " hay fever " is ap- 
plied ; not because the train of phenomena is always due to the influence of 
hay, but because by far the greater number of susceptible subj ects are thus 
periodically influenced by hay and by hay only. This form of the malady, hay 
fever proper, occurs only during the hay season, and is excited by the pollen 
from the grasses. Similar attacks in another group of individuals are 
excited by the pollen of the rose, not only periodically during its natural 
flowering season, but at any time when the individual is exposed to its influ- 
ence. A third group, located in certain geographical areas of the United 
States (Wyman), are similarly periodically affected by the pollen of the 
Ambrosia artemisisefolia (Marsh), a ragweed which is indigenous to those 
areas, and which flowers in the month of August, producing the autumnal 
" hay fever " of the United States, which is not hay fever at all. A fourth 
group are affected by aromatic substances of various kinds. A fifth group by 
such dusts as those of ipecacuanha powder, chamomile, etc. ; and so on. 

Dr. Ziem, of Danzig [Deutsche med. Woch., No. 39, 1885), has published a 
number of observations on the influence of aromatic substances on the nasal 
mucous membrane. Aside from the increase of preexisting hypersemiaof the 
erectile nasal tissues caused by inhaling the odors of fresh hay and of freshly 
roasted coffee, there is a group of similar effects from aromatic medicines — bal- 
sam of Peru, oil of peppermint, turpentine, pine-needle oil — used in nebulized 
or volatilized form in blenorrhoea or simple intumescence of the nasal mucous 
membrane ; and a group in which they are due to exposures to aromatic ma- 
terials in the way of business — from pepper, tobacco, flowers, and perfumery. 
The only treatment found efficacious is avoidance of the cause. Local treat- 
ment has been of no use. 

An amusing foot-note, by Ziem, is well worth reproducing. " The so-called 
reflex neuroses in nasal troubles have just become epidemic. One of the most 
remarkable performances in this field is a case reported" — the compiler for- 
bears to indicate where — " in which a child with a simple obstructive bron- 



260 PROGKESS OF MEDICAL SCIENCE. 

chitis could not be cured until his stopped-up nose had been healed. The 
case was described as a ' good example of vasodilator reflex toward the bron- 
chial mucous membrane.' The author, who had long held this case 'as a 

curiosity' until ' 's work first offered him an explanation/ seems to be 

wholly unaware of Kussmaul's observations on pulmonary hyperemia in the 
snuffles of children, and those of H'anisch, Voltolini, Rhoden and others, on 
the connection of certain lung affections with nasal affections. A curiosity is, 
above anything else, the safest fantasy to which the entire doctrine of reflex 
neuroses from nasal affections could be ascribed. Reflex neuroses here, reflex 
neuroses there, reflex neuroses everywhere! Less neurosis and more reflection 
would be better. The saying of Hippocrates that the nerves explain every- 
thing and nothing (consentientia et conspirantia omnia) is most applicable 
just in this connection." 

Under the caption of " Hay Fever, Asthma, and Allied Affections," Prof. 
Bosworth, of New York, presents {New York Med. Joum., April 24, p. 462, 
May 1, 1886, p. 486) a brief historical summary of professional views of this 
series of maladies, for which he prefers the name given by Herzog, rhinitis 
vasomotoria. A combination of three conditions, he believes, renders a person 
susceptible ; to wit, marked neurotic tendencies, morbid (stenotic) conditions of 
the nasal cavites, and exposure to the pollen or other germs and spores which 
produce the attack ; the diseases of the nasal passages being those only the 
tendency of which is to produce vascular turgescence with nasal stenosis. He 
has seen no cases without notable obstructive lesion in the nasal cavities. In 
few instances has he failed to afford marked relief by treatment entirely con- 
fined to the nasal passages. 

Nasal Reflexes. 
Dr. Emil Gruening, of New York {New York Med. Joum., Feb. 3, 1886, 
p. 192), has called attention to reflex ocular symptoms in nasal affections ; 
Dr. Thos. A. McBride, of New York {Idem) ; Dr. Harrison Allen, of 
Philadelphia {Med. News, March 13, 1886), to migraine and other headaches ; 
and Dr. Abram Jacobi, of New York {New York Med. Joum., Feb. 13, 1886, 
p. 193), to local choreic movements, all due to nasal and nasopharyngeal dis- 
eases. The most elaborate study, however, is that of Theodore Hering, of 
Warsaw, "Des Nevroses Reflexes determinees par les affectiens nasal es ; 
Asthme, Spasme larynge, Aphonie et Dyspnee spasmodique, Aphonie hys- 
terique, Migraine, Nevroses," etc., pp. 39, Paris, 1886 {Extrait des Annales des 
Maladies de V Oreille et du Larynx), to which we would especially call the 
attention of our interested readers. 

Adenoid Vegetations in the Nasopharyngeal Cavity. 
Dr. Michael, of Hamburg (reprint from Wiener Klinik, xii. Heft, December, 
1885), presents a short illustrated monograph, containing an excellent descrip- 
tion of the malady. He regards rude climate as the chief factor in its devel- 
opment, and attributes little importance to scrofulosis. In operating he 
prefers cutting forceps, similar to those used by the compiler for more than 
sixteen years, and has devised a special form of branch, so as to leave an 
elliptical space for the better protection of the uvula. He prefers operating 
in a number of sittings without anaesthetic narcosis. 



LAKYNGOLOGY. 261 

Neoplasms of the Nasal Septum. 

Dr. O. Chiari, of Vienna, reports and collates {Rev. Mens, de Lar., etc., 
Mars, 1886, p. 121) a number of cases, including seven mucous polyps, seven 
papillomas, three myxomas, three fibromas, one enchondroma, one adenoma, 
one myxofibroma, and one of unknown character. The main symptoms are 
epistaxis and obstruction. Hemorrhage is frequent after operation. 

Tuberculosis of the Larynx: Lactic Acid Treatment in the 
Larynx, Pharynx, and Nose, with Especial Keference to Tuber- 
culosis of the Larynx. 

Dr. Edmund Jelinek, of Vienna (Centralblatt filr die gesammte Therapie, 
Separat-Abdruck) confirms the observations of Krause (see this report, Jan., 
p. 313) as to the great value of lactic acid in the local treatment of tuberculosis 
of the larynx, in results with which the compiler's experience is in consider- 
able accord. This testimony, emanating from the large clinic of Professor 
Schr'otter, is of especial reliability. The remedy is most successful in the 
treatment of such ulcerations as are most accessible to the cotton wad with 
which the agent is energetically rubbed into the tissues in concentrated solu- 
tion of eighty per cent., or undiluted. Its efficacy is due to its destructive 
action upon diseased tissue and its innocuous influence on sound tissue, a 
combined influence not possessed by any other available agent. Jelinek 
reports a remarkable history in a tracheotomized subject, whose condition 
rendered it practicable to use the agent energetically without running any 
danger from spasm of the larynx. This would, we fancy, indicate the pro- 
priety of performing preliminary tracheotomy for the purpose of applying the 
remedy thoroughly under such anatomico-pathological conditions as would 
risk death by suffocation without this precaution ; the more so, as the necessity 
for the artificial opening would not be continuous, as it is so apt to be when 
that operation is performed in the same disease for relief from the agonies of 
stricture, or in the hope of putting the larynx at rest. Unless the diseased 
tissues can be so thoroughly eradicated that healthy tissue can be reached for 
cicatrization, and that without imperilling the sound tissues, every local 
remedy must fail ; and this, as argued in the memoir, is the reason that failure 
has resulted with other agents. It is recommended to begin with a 20 per 
cent, solution, followed as closely as can be tolerated with solutions of 50 per 
cent, and 80 per cent., and, finally, with the undiluted acid. Cocaine is to be 
used in cases of supersensitiveness. Ulcers are well wiped, as it were, with 
the cotton wad ; tumefactions should be more pressed upon. Energetic appli- 
cations are made daily until a sufficiently large eschar has been produced, and 
then they are suspended at that point until the slough has, at least in part, 
become detached ; weaker solutions being used meanwhile every day or two. 
In favorable instances, cicatrization will begin within two or three weeks. 
Swollen tissues subside under the influence of strong solutions penetrating 
into their substance, the result being the prompter the more succulent the 
tissue. A marked instance of this kind was recently under the compiler's 
care, in which a denuded epiglottis, apparently thicker than the patient's 
thumb, became reduced two-thirds in bulk within a week's daily use of a 



262 PROGKESS OF MEDICAL SCIENCE. 

solution of 80 per cent. This and further experience convinces him that 
Krause has led an important advance in the topical therapy of tuberculosis. 

Jelinek details a remarkable case of gangrenous pharyngitis cured in three 
weeks by twelve applications, after failure to arrest the process by the means 
usually practised in the hospital. He likewise refers to the value of lactic 
acid in the treatment of hypertrophic folliculous pharyngitis and hypertrophic 
rhinitis ; observations which can be confirmed by recent experience of the 
compiler. In applications to the nasal passages, however, Jelinek advises 
retention for half an hour or longer, of cotton tampons saturated with the 
remedy, as preferable to energetic rubbings. 

Cornu Laryngeum. 

A unique instance of " cornu laryngeum," a horny papilloma of the larynx, 
is recorded in detail by Dr. A. Jurasz, of Heidelberg [Berliner klin. Woch., 
1866, No. 5). It occupied the right vocal band, from which it was removed 
piecemeal with sharp-edged forceps. It had presented in recurrence after 
complete extirpation of a neoplasm of resistant, cartilaginous consistence, 
which had manifested a strong disposition to repullulation during removal 
in fragments, as opportunity was given. 

Fracture of the Larynx. 

A case of haematoma of the larynx due to traumatism has been reported by 
Dr. Perotti {Bold, delle malat. delle' orech., etc., No. 2, March, 1886 ; Rev. 
Mens, de Lar., etc., April, 1886, p. 222), in a person who fell during a tussle 
and was kicked in the anterior portion of the neck. Voice underwent 
gradual enfeeblement, severe dyspnoea augmented steadily, and death ensued 
in two hours. At the autopsy, abundant subcutaneous, dark colored, san- 
guineous infiltration was found on both sides of the larynx, more pronounced 
on the left. The interior of the larynx was obstructed by a sanguineous tumor 
of a deep blue color. The thyroid and cricoid cartilages were fractured. 

A supposed fracture of the thyroid cartilage with recovery after laryngotomy 
has been recorded by Dr. Manby ( The Lancet, January 9, 1886). 

Dr. Wm. Hunt, of Philadelphia, has suggested (vide The Medical News, 
May 1, 1886) that the death of Desdemona was due to fracture of the larynx. 

ECCHONDROSES AND EXOSTOSES OF THE LARYNX. 

M. Henry Bertoye, of Lyons, has published an article [Annales des 
Maladies de V Oreille, du Larynx, etc., April, 1886, p. 125) comprising a summary 
of the cases previously reported, and the record of a personal observation. 
His patient, a man set. 42, entered the hospital in a semi-asphyxiated condi- 
tion. Tracheotomy was performed. Pulmonary complication ensued, and 
death took place seven days after the tracheotomy. A large, roundish tumor 
had been detected laryngoscopically beneath the vocal bands. On opening 
the larynx posteriorly, a hemispheroidal tumor, of the volume of a large 
almond, was found on the right side of the internal face of the cricoid car- 
tilage. It proved to be an ecchondroma. Some excellent remarks follow, on 
pathology, diagnosis, and treatment. 



LARYNGOLOGY. 263 

Carcinoma of the Larynx. 

Dr. W. Lublijstsky ( Ueber den Kehlkopfkrebs, Berliner medicinische Gesell- 
schaft, Sitzung, Dec. 9, 1885; Berliner Jclinische Wochensehrift, Feb. 22, M'arz 1, 
u. 8, pp. 122, 142, 152) deplores the indefiniteness of our knowledge of the 
etiology and clinical course of this disease, in the interest of its early recog- 
nition, in order that the utmost benefit may be derived from the great progress 
made in operative treatment. It is just this early recognition which betters 
the prognosis, both as to life and phonation, from partial resection, as per- 
formed by Hahn and others. From this point of view, Lublinsky deems it 
necessary to investigate more closely the diagnosis as deduced from a great 
number of observations. Carcinoma of the larynx is usually primary, and 
spreads thence to neighboring organs. It is much less frequently an extension 
from neighboring organs, and least frequently a metastasis, inasmuch as the 
larynx is little disposed to become the seat of metastatic neoplasm. While its 
etiology is very obscure, it is evident that conditions of irritation precede its 
development. Thus men are affected more frequently than women ; in the 
proportion of fourteen to four in the author's cases. Six of these men were 
strongly addicted to the abuse of spirituous liquors, and three to tobacco. 
Heredity is not to be left out of consideration. The brother of one of the 
author's cases had had laryngeal carcinoma; the father of one, gastric carci- 
noma; and the mothers of two, mammary and uterine carcinoma. The 
influence of other cachexias, especially that of phthisis in the parents, is 
doubtful. As a rule, the constitution is vigorous, and in marked contrast to 
the severity of the malady. Previous injury is to be taken into consideration. 
One of the author's patients dated his disease from a severe choking to which 
he was subjected. Most cases occur in the latter half of life. Thus, of the 
18 patients alluded to, 1 was below 40 years, 5 between 40 and 50, 9 between 
50 and 60, and 3 between 60 and 70. As shown by numerous observations, 
any portion of the larynx may be the seat of the primary affection. Of the 
18 cases of the author, only 11 could be utilized in determining this point. 
The epiglottis was the point of departure in 5 cases, the ventricular band in 
2, the vocal band in 2, the arytenoid cartilage in 1, and the arytenoepiglottic 
fold in 1. The left side was occupied in 7 cases, the right side in 4. In 2 
-cases the extension was toward the base of the tongue, in 3 toward the interior 
of the larynx, and in 3 toward the oesophagus. In the vast majority of cases 
the carcinoma is an epithelioma (squamous-celled, Butlin). The differential 
diagnosis can hardly be safely made laryngoscopically at first, and the re- 
moval of fragments for examination is requisite. 

So far as symptoms go, hoarseness is the most important, and it long pre- 
cedes all other manifestations. Then come irritating cough and expectora- 
tion, neither of them pathognomonic, as they accompany nearly all diseases 
of the respiratory organs. Pain on pressure upon the larynx, and spontaneous 
pains follow. The pains recur at intervals, long at first, and gradually shorter 
and shorter, eventually interfering with rest at night. Later in the case the 
pains dart toward all directions. Nearly simultaneously with the pains, dys- 
phagia begins to be experienced. At a later stage stenosis of the larynx 
takes place; but, as the obstruction in the respiratory channel is gradually 
progressive, sudden dyspnoea does not occur. It is manifested at first only 
upon great exertion, but gradually increases to such an extent as to necessi- 



264 PKOGRESS OF MEDICAL SCIENCE. 

tate operative intervention, the more that clanger of syncope is imminent, as 
well as the paroxysms of suffocation. Hemorrhages occur, often before the 
formation of tumor, apparently the result of irritation of the mucous mem- 
brane by the developing neoplasm. These hemorrhages are insignificant, in 
comparison to others liable to follow erosion of large bloodvessels. The 
external conformation of the throat affords digital indications of the diag- 
nosis in exceptional cases only. Intumescence of the neighboring glands is 
by no means a constant phenomenon. The patient's condition is tolerably 
comfortable so long as there is no ulceration or extension of the neoplasm 
in depth. The most important diagnostic agent is the laryngoscopic explora- 
tion, to the aid of which microscopic examination of fragments must be 
instituted. In the early stages there are a variety of forms under which the 
disease is presented, until the process passes in all forms into a general and 
almost indifferential picture of extensive ulceration. Mistakes can be made 
for lepra and lupus, and still more readily with tuberculosis and syphilis. 

The prognosis is very sad. When the process is left to itself, no other 
outcome but death is to be anticipated. The average tenure of life in twelve 
of the author's cases unsubmitted to operation was two years and a half. 
Pneumonia and exhaustion are the most frequent immediate causes of death; 
then come pleuritis, syncope, and asphyxia. The sole method of saving life 
is complete removal of the diseased tissues. Tracheotomy makes no effort at 
cure, but surrenders the patient to his general cachexia and to whatever 
inconvenience may follow extension of the disease through the wound. 
Laryngectomy, therefore, or when possible partial removal of the diseased 
tissues, is the course to be striven for when no special contraindications exist. 
The dangers of the operation are being reduced under better technical pro- 
cedure, and better after-treatment. 

Neuroses of the Larynx. 

An instance of aphonia of about one hour's duration, habitually following 
hypodermic injections of morphia in a case of delirium tremens has been 
reported by Dr. Treuvelot (Joum. de rnecl. et de Chir., March, 1886; Brit. 
Med. Joum., March 20, 1886, p. 563). Examples of spastic aphonia and dyspnoea 
(reflex) from nasal lesions have been reported by Dr. Brebion (Ball. et. mem. 
de la Soc. Franfaise d'otologie et de laryngologie, t. 11, 1886, p. 14), and Dr. 
Hering (Idem, p. 19, and Annates des Mai. de V Oreille, du Larynx, etc., Fevrier, 
1886, p. 45; March, 1886, p. 89) similar to that reported by Michael, of Ham- 
burg (Wien. med. Presse, 1885, No. 41). In several of these instances trache- 
otomy became necessary, despite relaxation of the spasms under anaesthesia. 
Space is not at our disposal for a summary. The papers are valuable and 
ably written. Some years ago, Dr. Thaon, of Nice, reported a case attributed 
to hysteric paralysis of the dilators of the glottis, in which tracheotomy had to 
be performed twice. 

Spasm of the Larynx in Hydrophobic Tetanus. 

Dr. Conrad Brunner details (Berliner Mm. Wochenschrift, Feb. 15 and 
22, 1886, pp. 101 and 126) two cases of hydrophobic tetanus, the respiratory 
spasms in which he attributes not only to spasm of the thoracic muscles and 



LAKYNGOLOGY. 265 

the diaphragm, but to intense spasm of the adductor muscles of the larynx in 
addition, especially because the asphyxia did not reach so high a grade during 
the paroxysms, after tracheotomy, as before the operation. 

Paralysis of the Larynx. 

In a "Note sur les paralyses laryngees d'origine centrale," in La France 
medicate, Nos. 134 et 135, t. ii., 1885, Dr. A. Cartaz records, among others, 
a few personal observations, chiefly from the service of Prof. Charcot, tending 
to shoAV that at the commencement of progressive bulbar paralyses, it is the 
phonator group of muscles, the lateral and transverse adductors, and the ten- 
sors, which are first affected. These are examples of paretic conditions merely, 
and not of complete paralysis. It may be stated that paretic conditions, 
similarly limited, in the domain of the abductors or dilating muscles, would 
probably elude detection, inasmuch as there is no distinct point to mark the 
extreme limit to the outward excursion of the vocal bands as is afforded by 
the median line to mark the extreme limit of normal excursion inward. In 
another personal observation made upon a hemiplegic subject in the service 
of Landouzy, a paralysis, accredited as abductor paralysis, is evidently a com- 
plete paralysis; for the vocal band is described as being in the cadaveric 
position. Observations in similar instances reproduced from records by Lewin 
and by Delavan are free from this doubt, for the vocal band is described as 
remaining immovable at the median line. Three cases are reproduced from 
Mackenzie, with paralysis in the cadaveric position, and three with abductor 
paralysis ; with two of the latter character from Gerhardt, and one from Pen- 
zoldt. Allusion is made to Semon's valuable researches on paralyses of the 
posterior cricoarytenoid muscles, and to a recent [Revue de med., 1885) critical 
review by Lannois upon a presumptive cortical centre for the larynx. The 
author refrains from any theoretical application of the observations he has 
made and collected, until he shall have had opportunities for learning whether 
the lesions in his own cases undergo modifications with the progression of the 
diseases which have produced them. 

Stricture of the Trachea. 

Dr. J. Dreschfeld, of Manchester, in discussing this subject in The Medi- 
cal Chronicle for Dec. 1885, p. 177, reports a case in which the characteristic 
pulse-tracing of aneurism was produced at the left wrist. At the autopsy, 
the left bronchus was so much narrowed as scarcely to admit a crowquill. 

Dr. Gougenheim, of Paris, reports, in Annates des Mai. de V Oreille, du 
Larynx, etc., Fevrier, 1886, p. 65, two cases of stricture of the trachea and the 
right bronchus, syphilitic in origin, rapidly ameliorated under large doses of 
potassium iodide. 

A. Robin, of Paris {Idem, p. 77), reports a case of stricture in which an 
aneurism of the arch of the aorta ruptured during the introduction of the 
canula after tracheotomy, with death at once by hemorrhage. At the autopsy, 
an aneurismal pouch was found which opened into the trachea at the anterior 
.face of its lower portion. The cartilages were absorbed. The perforation had 
been produced by pressure of the extremity of the canula upon the projecting 
portion of the aneurism within the trachea. 



266 PROGRESS OF MEDICAL SCIENCE 



DERMATOLOGY. 



UNDER THE CHARGE OF 

LOUIS A. DUHRING, M.D., 

PROFESSOR OF DERMATOLOGY IN THE UNIVERSITY OF PENNSYLVANIA, 

AND 

HENRY W. STELWAGON, M.D., 

PHYSICIAN TO THE PHILADELPHIA DISPENSARY FOR SKIN DISEASES. 



Therapeutic Use of Lanolin. 

Lassar, in the Berl. hlin, Wochenschr., 1886, No. 5, speaks highly of the 
value of this new remedy as a basis for ointments. He finds that when 
rubbed into the skin it disappears almost immediately. If other fats are 
rubbed in side by side with lanolin, this latter substance can readily be 
detected by the feel, the skin becoming more turgid, while with the other 
fats it becomes more supple. On the skin of the cadaver it may be pressed 
in much further than other fats, the horny layer of the epidermis being 
penetrated, and it may be detected microscopically in the network of the 
corium. The experiment was made with cinnabar and lanolin. The author 
used lanolin upon some four hundred patients, and found that it was very 
well tolerated, especially so in those cases where, from the nature of the 
disease, the skin is irritable. As a base for ointments it is to be particularly 
recommended where deep penetration is desired, as in syphilis, psoriasis, and 
tinea tonsurans. Where it is desirable to produce suppleness of the skin, 
the lanolin may be advantageously mixed with twenty per cent, of vaseline 
or cosmoline. 

As examples of its therapeutic action, a case of acute eczema of the face in 
a child of three years, is mentioned as having been rapidly cured with sali- 
cylated (two per cent.) lanolin ; also a case of impetigo contagiosa, in which 
a paste consisting of lanolin 50 parts, salicylic acid 2 parts, oxide of zinc and 
amylum aa 24 parts, was quickly curative. An obstinate case of pityriasis 
versicolor was promptly relieved with three inunctions of an ointment con- 
sisting of lanolin, 88 parts ; sulph. prsecip., 10 parts ; ac. salicylic, 2 parts. 
In inveterate scabies, in callositas, and especially in acne and sycosis, is an 
ointment such as the following, possessing the penetrating properties afforded 
by lanolin, useful: R. Naphthol, 5-10 parts; saponis viridis, eretse alb., 
sulphur, prsecip., lanolin, aa 25 parts. As recommended by Ihle, of Leipzig, 
the author found a 5-10 per cent, resorcin-lanolin salve to be an efficient 
application for tinea sycosis. In psoriasis, the author had good results from 
the use of a 25 per cent, chrysarobin-lanolin salve, with much less chance of 
the chrysarobin dermatitis. In the inunction treatment of syphilis, the 
lanolin-base is an improvement. In simple seborrhoea, lanolin may be em- 
ployed with advantage alone, or in combination with sulphur, carbolic acid, etc. 

In the discussion which followed, Patschkowski stated that he had experi- 
mented with a potassium-iodide-lanolin salve, as regards its ready absorb- 
ability, and with satisfactory results. Fr'ankel remarked that in application 



DEKMATOLOGY. 267 

of lanolin preparations to the mucous membrane, he found that the base pre- 
vented crust-formation, and, to a certain extent, diminished the secretion. 
Kobner could, in the main, confirm the author's statements, but he found that 
lanolin did not hold chrysarobin in solution, but that the ointment appeared 
simply as a mixture. Vaseline proved a better solvent, but for ointments of 
chrysarobin, lard is the best base, as this drug dissolves completely in this 
when the ointment is properly made. Another disadvantage of lanolin is its 
tenacity, the speaker finding that inunction with the ordinary mercurial oint- 
ment was much more satisfactory than when lanolin was substituted — even, 
in fact, when, instead of a pure lanolin base, 20 per cent, of lard was incorpo- 
rated. He could, however, corroborate the statement of Liebreich that, in 
general, medicinal substances such as potassium iodide, etc., incorporated in 
lanolin, penetrated the skin and were absorbed. Lanolin makes a much 
better ointment-base when 10-20 per cent, of lard is added. In the use of 
tar, vaseline seemed to be more satisfactory as a base than lanolin. Liebreich 
remarked that in the ordinary gray ointment, the pharmacopoeia calls for a 
rubbing up of the mercurial until the globules are no longer visible to the 
naked eye ; with lanolin-mercurial salve, on the other hand, it requires a sharp 
microscopical examination to detect a trace of the quicksilver. All other 
bases occasionally proved irritating to the skin ; as yet, no such observation 
had been made concerning lanolin. Chrysarobin, he found to be but slightly 
soluble in any fatty base — no more so in lard than in lanolin. A great ad- 
vantage in the use of lanolin as an ointment-base is its property of taking 
up water. Liebreich mentioned the fact that lanolin had been employed in 
medicine years before, but subsequently, as a medicinal agent, dropped out of 
sight. Lassar concluded the discussion by remarking that another satisfac- 
tory use he had made of lanolin, mixed with "Buenos Ayres wound-powder," 
was as an absorptive dressing for secreting ulcers, etc. 

Dermatitis Ferox. 

J. L. Milton, of London, in the Edinburgh Medical Journal, for March, 
1886, describes, with this title, a rare and peculiar form of cutaneous inflam- 
mation which he thinks has not heretofore been described. The outbreak 
takes the form of one or more scattered patches on the face, hands, or chest, 
which are reddish, speedily becoming of a vivid red or lake color, and later 
brownish, the epidermis crumpling and peeling off or continuing to exfoliate. 
Occasionally a small patch may ulcerate. There is usually no discharge. The 
patches generally form very slowly, and, as a rule, it is only later that the 
health begins to suffer; but in other cases the health begins to fail within a 
few days after the appearance of the eruption. Sometimes when the disease 
attacks the side of the face in the male, firm crusts form, so that at the end 
of a week the case looks like one of rather advanced erythematous sycosis. 
Such crusts may crack, and may look as if thick serum were exuding from 
them, but in the early stages, at least, there is no weeping as in eczema. 

In every case which has come under the observation of the author, the 
affection of the skin showed itself first, the constitutional disturbance mani- 
festing itself later. The patches are irregular in shape, generally quite 
isolated, and usually of a lake color. In two cases the hue was that of 



268 PROGRESS OF MEDICAL SCIENCE. 

carmine, and the constitutional disturbances were out of all proportion to 
the extent of the skin affected. The patches often take on an angry look, as 
though they had been " burnt with fire." Occasionally the lesions assume a 
papular form, and then resemble " flattened aggregated lichen spots," over- 
laid by a horny cuticle. There is grave disturbance of the health, with loss 
of appetite, nausea, headache, inability to walk straight and prostration. 
The disease bears some resemblance to erysipelas and acrodynia, but is 
distinct from both. The notes of a case are given at length, the woman, 
after several relapses during nine months, completely losing her health, and 
finally dying of pneumonia. 

Etiology of Alopecia Areata. 

Max Joseph (Centralbl f. d. med. Wlssenschqften, 1886, No. 11), of Berlin, 
in the course of an extended series of experiments conducted in the Univer- 
sity with the view of determining the significance of the trophic nerves, 
obtained results which, he thinks, throw light upon the nature of alopecia 
areata. The experiments consisted in section, peripherally from the ganglion, 
of the second cervical nerve in cats and rabbits, the operation being followed 
by symptoms of the cutaneous and hairy systems having the greatest resem- 
blance, if not identity, with alopecia areata in man. Five experiments are 
detailed. The conclusion arrived at is that this disease must be regarded as 
a result of disturbed tixmhic innervation. 

Resorcin in Acuminated Warts. 

Cesar Bceck, of Christiana {Monatshefte fiir praktische Dermatologie, March, 
1886), while admitting that in most cases the treatment of acuminated warts 
is satisfactorily accomplished by means of scissors or a sharp spoon, states that 
for obstinate, intractable, or recurring cases we have a useful remedy in resor- 
cin, which he has employed for the last three or four years. After instru- 
mental removal of the wart, to prevent a recurrence, he directs a four or five 
per cent, aqueous solution to be applied four or five times daily, to be continued 
several weeks. In most cases so treated no recurrence of the disease takes 
place ; should such occur the author resorts to the application of the remedy 
in powder form with sugar, bismuth, or boric acid, one part to eight parts of 
resorcin, care being taken to watch the patient from day to day, to guard 
against undue excoriation or cauterization. Used in this manner, as a rule, 
a few days suffice. The remedy is particularly useful in chronic cases that 
have been already much treated, where the wart is no longer pointed, but is 
flat, thick, and spread out. 

Leucoderma Syphiliticum. 

O. Rosenthal {Berl. klin. Wochenschr., No. 3, 1886) presents the case of a 
woman, thirty years of age, suffering with positive signs of secondary syphilis, 
who, four months after infection, showed a deep dark-yellow chloasma, occu- 
pying the greater portion of the face. The woman had been married six or 
seven years, had been healthy, but had never been pregnant, nor had she 
manifested any signs of uterine disease. After the internal use of iodide of 
mercury and iodide of potassium the syphilitic symptoms disappeared, except 



DEKMATOLOGY. 269 

the chloasma, which only became paler. Three months later there occurred 
a syphilitic relapse, together with whitish spots of leucoderma, of the size of 
a bean or small coin, situated on a darker background on both sides of the 
neck, where previous]y no roseola had existed. After a course of treatment 
with injections the syphilitic symptoms disappeared, but the chloasma and 
the leucodermic lesions remained. The author regards the view of Eiehl and 
of Taylor as correct, namely, that the affection consists not in a loss of pig- 
ment, but in an increase of pigment irregularly distributed. 

Rhinoscleroma. 

Prof. Kobnee, of Berlin, in the Deufsch. med. Wochenschr., No. 26, 1885, 
presents a case of the rhinoscleroma of Hebra, which he thinks should more 
properly be designated " rhino-pharyngo-scleroma," an opinion based upon 
an investigation of the forty published cases as well as of the five personally 
observed. The case reported is the first met with by the author during his 
residence in Berlin, and concerns a strong, athletic man, forty-six years of 
age, the disease having first manifested itself ten years previously. The 
nose was deep red and very hard to the touch, the cartilaginous portion 
remarkably spread out, flattened, and the septum broadened to four or five 
times its natural size. The hardness arose from a bulky new growth seated 
in the alse, septum, and base of the nose, protruding slightly from the 
nares, and having the appearance of a flat fungus. The undermost of these 
growths, the size of half cherries, resembled dark red, thinly crusted, uneven, 
flat condylomata, incision occasioning much pain and bleeding. The lesions 
completely obstructed the nares. The velum palati was the seat of a warty, 
partly scarred, extremely hard lesion covered w r ith shallow erosions or ulcera- 
tions. On the right side, on the border of the hard palate existed a sharply 
circumscribed, prominent, extremely hard, smooth, and intact swelling, the 
size of a bean. The uvula was destroyed, it being the seat of a rigid, whit- 
ish-yellow, glistening, much- thickened, scar-like mass. The posterior wall of 
the pharynx, the larynx, and trachea, were also affected. 

A case of rhinoscleroma, similar to the foregoing, is reported by Drs. 
Payne and Semon, in the Trans. Lond. Path. Soc, 1885, chromolithographic 
plates accompanying the paper. The patient was a young man, a native 
of Guatemala. Concerning the pathology, the authors state that in this 
case the growth was one essentially belonging to the skin or mucous mem- 
brane, but infiltrating to some extent deeper parts. The most character- 
istic portion of the neoplasm was that in the derma, which was profusely 
infiltrated with a small-celled growth, the elements of which resembled 
those of granulation tissue, being indefinite in shape or spherical with one 
large nucleus. In some parts they were much more elongated, spindle- 
shaped or flat, resembling the fixed cells of connective tissue. The cells were 
contained in a loose areolar connective tissue, not unlike that of some granu- 
lations, but in places this was more distinctly fibrillated, and the elements 
more spindle-shaped. In some places the connective tissue was composed 
of very dense thick fibres, with scanty cellular elements, looking almost 
hyaline, and resembling the tissue of a scar. There were no indications of 
atrophy or degeneration in any part of the growth. The observations recorded 



270 PROGKESS OF MEDICAL SCIENCE. 

agree generally with those of Kaposi, though he interprets the appearances 
differently. They accord more precisely with the results of Mikulicz. The 
characters are different from those of any other new growth, and are pecu- 
liar ; the authors inclining to place the disease in the class of granulation 
tumors, with tubercle, lupus, syphilis, etc. The disease is very rare in Eng- 
land, this case (so far as the authors are aware) being the first authentic one 
on record in that country. 

Janovsky, of Prag, likewise reports a similar case in the Wiener med. 
Presse, No. 14, 1886 of this disease, in which treatment with the sharp spoon 
was followed by beneficial results. Moreover, through the shrinking of the 
tissues that had been operated upon the surrounding areas were also favorably 
influenced. 

[The rarity of the disease in this country (no well-marked cases having as 
yet been reported in the United States, we believe) and the fact that it is liable 
to be mistaken for a syphilitic manifestation, render the subject especially 
interesting. It was originally thought by Hebra and Kaposi to be a variety 
of sarcoma, but this view has not been entertained by other competent ob- 
servers. The histological examination by Geber, Mikulicz, Pellizzari, and 
others, show the growth to be a profuse round-cell infiltration, which later 
passes into a diffuse connective-tissue new growth. — Eds.] 

Papayotin in Glosso-pathology. 

Schwimmer, the well-known dermatologist of Budapest, speaks favorably 
in the Wiener med. Wochenschr., Nos. 8, 9, and 10, 1886, of papayotin in cer- 
tain affections of the tongue and mucous membrane. After referring to the 
value of the drug in rapidly softening and loosening the diphtheritic mem- 
brane, in the strength of a five or ten per cent, solution, as shown by the 
observations of Koths and Asch, Krause and Frankel, the author dwells upon 
leucoplakia buccalis, characterized by peculiar patches of diseased and thick- 
ened epithelium, and the difficulty of its cure in many cases. He alludes to 
the in efficacy of vaunted remedies, such as solutions of soda, corrosive subli- 
mate, chromic acid, nitrate of silver, alcohol, and ether spray, and, finally, 
lactic acid, which has been recently recommended by Dr. Joseph, of Berlin. 
Schwimmer has had a large experience with leucoplakia, which is in this 
country a rare disease. Twenty-five cases are alluded to, brief notes of ten 
of these being given in tabular form. The opinion is expressed that from 
an experience of two years with papayotin it is a remedy which acts happily 
on the free epithelium, allays pain, and aids the healing process. It is recog- 
nized that in the course of this disease, so long as the continuity of the epi- 
thelium remains unbroken, no subjective symptoms are usually present; but 
that, as the process proceeds, and accidents, fissures, or ulcers occur, more or 
less pain is experienced. 

In other idiopathic ulcerations and fissures of the tongue also the author 
has found papayotin of value. One case of tuberculosis of the tongue is 
cited, in which it acted most satisfactorily. The following formula was em- 
ployed : 

R.— Papayotin 0.50-1.0 

Glycerinse, 

Aq. dest aa 5.0. 



DERMATOLOGY. 271 

The surface, after being dried, is painted from two to six times daily with 
a soft brush. The purest papayotin should be employed, there being in the 
market much that is adulterated. The explanation of the wbrking of the 
drug is found in its remarkable digestive action upon the loose and diseased 
epithelium, causing this to be cast off, thus allowing a healthier epithelial 
reproduction and healing to take place. 

Delhi Boil. 

J. Hickman contributes to the Practitioner, for January, 1886, an interest- 
ing paper on this disease, based upon cases observed in Umballa. The affection 
begins as a tense and glistening spot usually about a hair follicle, becoming a 
vascular and slightly reddened, usually painless, tubercular elevation, indo- 
lent, and with hardened base. After from five to ten days the central portion 
of the tubercle begins to exfoliate in the form of small, dry, glistening scales, 
which process is repeated several times, eventually extending to the base of 
the lesion. The tubercle becomes more red ; is yielding to the touch ; the 
envelope semi-translucent, through which can be seen small vessels, and later, 
some yellowish points. At this time also, on pressure, serum may be made 
to exude. Gradually the deep layers of the skin become involved ; serum 
exudes through a central opening, and dries to large, yellowish-brown crusts, 
marked by " dissepiments." In one instance, the disease remained permanently 
in this stage. Ordinarily, however, suppuration and ulceration progress un- 
der the crust, new tubercular elevations are generated and in turn break 
down, the ulceration finally extending beyond the crust, the latter gradually 
shrivelling and disappearing, leaving an elliptical ulcer with irregular and 
clipped perpendicular edges, and a base consisting of a mass of reddish granu- 
lations dotted with dark points and covered with pus, at times tinged with 
blood. The ulcer enlarges, new tubercles appearing about the infiltrated 
edges, and seen in their different stages. The disease may remain in this 
stage indefinitely, indolent and intractable to treatment. The adjacent 
glands and lymphatics are often at this stage enlarged. Healing, when it 
occurs, takes place from the centre outward. It is gradual, and the new 
tissue may at any time undergo retrogressive change and ulceration, the ulcer 
returning to its original condition. The cicatrix is shallow, somewhat de- 
pressed, striated, sometimes contracted, and eventually of a brownish-yellow 
color. 

The disease is very liable to attack abraded surfaces, excoriations, etc. The 
wrist, and the region immediately above, are common sites for the disease. 
Then follow in order of frequency, the elbow, back of foot, face, and the lower 
limbs ; the trunk is seldom attacked. In patients suffering with grave systemic 
disorders, as leprosy, syphilis, and tuberculosis, the disease usually assumes 
a serious type, and may give rise to extensive sloughing, and even bone 
necrosis. In the diagnosis the clinical history and its obstinacy are positive 
factors. It very closely resembles the tubercular or gummatous syphiloderm. 
Heredity plays no influence. It is apparently distinct from furuncle. But few 
cases are met with in those past the age of thirty, and rarely before puberty. 
It is not contagious, but is inoculable. Microscopically the structural changes 
are seen to be about the same as observed in lupus. So far, the weight of 
observation indicates that the origin of the disease is to be found in impure 



272 PROGKESS OF MEDICAL SCIENCE. 

water-supply, and that the immediate causative agent is the presence of a 
specific micrococcus, as established by the experiments of Boinet and Despard, 
and Duclaux*. The plans of treatment most successful are those now com- 
monly employed in lupus: caustics, the knife, and the curette. Tonics are 
also given. Nothing is so certain, however, as a change of climate ; recovery 
follows in almost every instance. 

Hereditary Predisposition to Bleb-formation. 

Max Joseph contributes {Monatshefte fur prakUsche Dermatologie, 1886, 
No. 1) an interesting report of four cases — a mother and her three children. 
The woman was aged thirty-seven, and suffered with the affection since her 
fourth year. It had never been previously observed in the family. In all 
regions where pressure from clothing, etc., occurred, blebs, varying in size 
from a pea to a silver quarter-dollar, would arise. The bullae were unaccom- 
panied by fever, and the subjective symptoms were slight; trifling itching was 
noted. The season had a marked influence ; the skin being almost entirely 
free in winter, the eruption appearing most marked in summer. The indi- 
vidual blebs disappeared in the course of several days by gradual absorption 
and desiccation ; or if the bleb wall was accidentally ruptured, a slight and 
discharging excoriation would result, which, however, would readily heal 
under simple applications. The general health of the patient was good. In 
other respects the skin and its functions were normal, except that urticaria 
factitia could be readily called forth. The woman's oldest child aged fifteen 
years, and the second, aged twelve years, showed similar blebs, but in these 
as also in another (third) child, the feet were the region mainly involved. In 
these cases the affection had existed since infancy, disappearing entirely in 
winter. 

The Treatment of Eczema and Impetigo in Children by the 
Internal Use of Chrysarobin. 

A series of cases of eczema and impetigo is reported {Monatshefte fur prak- 
Usche Dermatologie, Jan. 1886) by Stocquart, in al] of which chrysarobin, 
administered in varying doses, effected rapid cures. The cases exemplified the 
moist and impetiginous varieties of eczema, and the first effect of the drug is 
seen in the lessened secretion. The daily dose varies from a few milligrammes 
to several centigrammes, depending upon age and susceptibility. The average 
duration of treatment was a week to ten days. The author considers the 
favorable action of the drug to be due to its constringing effect on the 
capillaries. 



MIDWIFERY. 273 



MIDWIFERY 



UNDER THE CHARGE OF 



FRANCIS H. CHAMPNEYS, M.B., F.R.C.P., 

OBSTETRIC PHYSICIAN TO ST. GEORGE'S HOSPITAL. 



On the Lower Segment of the Uterus. 

The Centralbl. f. Gyn. for November 7, 1885, contains a summary of a paper 
read on the above subject by Hofmeier, before the Obstetrical and Gyneco- 
logical Society of Berlin. Impressed with the great difference of opinion, and 
the practical importance of this subject, Hofmeier resolved thoroughly to 
reinvestigate it with the help of all the anatomical material accessible to him. 
Apart from numerous uteri in the post-partum condition, he obtained seven 
uteri of pregnant women, and one from a woman who died during labor, all 
of which were carefully hardened, and then examined. He attempted, with 
their help, to answer the questions: 1. Is the cervix maintained as a canal 
till, or nearly till, the beginning of labor ? 2. If so, is there a segment of the 
uterus which differs anatomically from the remainder of the organ, and which 
should therefore be spoken of as the "lower segment of the uterus?" Lastly, 
he attempted to connect the phenomena of contraction, which have been 
recognized since Bandl's investigations, with the anatomical characters. 

In answering the first question, Hofmeier relied almost exclusively on the 
differences in anatomical structure between cervix and uterus for determining 
what was cervix, and he found that in all his preparations the cervix could 
easily be distinguished, and invariably maintained its shape. In a few in- 
stances, it is true, a slight funnel-shaped expansion toward the uterine cavity 
was present, but on considering the whole case both anatomically and clini- 
cally, he concluded that this was certainly to be explained as due to labor 
pains. Since at the margin of the anatomically well-defined cervix, the other 
characteristic landmarks were also present, and, on the other hand, the mar- 
gin between the cervix and uterus was always spoken of as the internal os uteri, 
Hofmeier infers that the portion of the cervix which in the non-gravid uterus 
is spoken of as internal os uteri, also forms the boundary of the uterine cavity 
in the pregnant organ until the on£et of "pains." 

2. The " contraction-ring " invariably forms along the line of the firm attach- 
ment of the peritoneum to the uterus, which line in the pregnant organ always 
lies four or five cm. above the internal os described above ; this portion of the 
uterus should, therefore, be spoken of as the "lower segment of the uterus." 

From its naked-eye anatomical structure it appears to belong to the uterus, 
not to the cervix, in which the muscular bundles of lamellae diverge. In its 
minute, and especially in its microscopical structure, it, however, shows cer- 
tain characteristic peculiarities by which it differs from the proper body of 
the uterus, and which justify a special name. Physiologically this lower 
segment belongs to the cervix, since, as shown by several direct observations, 
it is probably passive from the beginning of labor, and takes no, or almost no, 
share in the active contraction of the rest of the uterus. After expulsion of 
the foetus, it is always perfectly passive. Pathological stretching of this seg- 

NO. CLXXXIII. — JULY, 1886. 18 



274: PROGRESS OF MEDICAL SCIENCE. 

ment, as a rule, only occurs where there is great mechanical obstruction, or, in 
multipara?, after incomplete involution. 

Parturition during Hypnotism. 

Pritzl, in the Wiener med. Wochenschrift, Nov. 7, 1885, relates a case illus- 
trative of the conditions named above : S. M., ret. twenty-six, primipara, was 
admitted to the Lying-in Hospital September 10, 1885. Previous health 
good; no neurotic history. While the woman was in the hospital, it was 
found that she could easily be rendered hypnotic by steadily looking at a 
shining thermometer bulb. In order to induce this condition, the bulb was 
held about six inches from her eyes and moved slowly to a point a little above 
them. As soon as her eyes turned up in a state of convergence, generally 
after looking for ten seconds, she became unconscious, insensible to pricks 
with a needle, and touching her cornea, etc., caused no reflex. 

During the night of October 30, the premonitory signs of labor appeared. 
Pritzl examined the patient on the 31st, and found the foetus in the second 
position, the external os admitting two fingers. At eight P. M. the os had 
dilated enough to admit three fingers. Pritzl then ruptured the membranes, 
whereupon the pains grew stronger. The patient became greatly excited, 
throwing herself about and showing all the signs of severe labor pains. 

At this stage Pritzl resolved to induce hypnotism in the usual way. One 
look at the shining bulb sufficed to render the woman devoid both of con- 
sciousness and sensation. This was done at 10.45 p. M. 

The pains, now that the woman was hypnotic, differed in several respects 
from their previous character. When the woman became unconscious, the 
interval between the pains averaged almost two minutes; the pains them- 
selves increased in severity, and lasted on an average fifty seconds. While at 
the acme of each contraction, the abdominal muscles cooperated vigorously, 
certainly not less so than during ordinary labor. As long as the pains lasted 
the woman remained perfectly unconscious, though at times she flexed her 
left forearm and showed some stiffness in the left leg. Her head, too, was 
tossed from side to side, and now and then she frowned and groaned; during 
the intervals between the pains she lay perfectly still, as if asleep. 

The strong pains did not remain ineffectual, and the os uteri became easily 
stretched by the advancing head ; at the twelfth pain the vertex slid over 
the perineum through the vulvar fissure, and the child was born at 11.15 
p. m., weighing 2900 grms., measuring 50 cm. in length, and it began at 
once to cry lustily. After a period of repose, lasting five minutes, the uterus 
again began to contract energetically, the pains now lasting for a somewhat 
shorter time than they did during the expulsive period (on an average, thirty 
seconds), though equal to them in severity. 

The abdominal muscles were used with more energy than Pritzl had ever 
seen them in the after-birth period. The placenta was not expelled into the 
vagina till the fourteenth pain, whereupon uterine contractions ceased. 
After waiting three-quarters of an hour, Pritzl removed the placenta by trac- 
tion on the umbilical cord. The mother was then waked by shouting and 
shaking her, and, more than all, by liquor ammonias fort, being given her to 
smell. On becoming conscious, she was extremely surprised at the comple- 



MIDWIFERY. 275 

tion of her labor, and declared that, from the moment when the bulb was 
held before her eyes she had slept well. The post-partum period passed off 
normally in every respect. 

On the Form of the Uterine Muscle-curve and on Peristalsis of 
the Human Uterus. 

In the Centralbl.f. Gynakologie, Oct. 3, 1885, a summary is given of Schatz's 
investigations relating to the above. He finds that in some cases the ascend- 
ing and descending portions of the muscle-curve are exactly alike, except 
that the latter presents a longer tail, much as is seen in contraction-curves of 
striped muscles. As a rule, however, the ascending portion is considerably 
steeper than the descending, the reverse being only rarely met with. Schatz 
was at first inclined to think that the slowly descending curve was due to 
exhaustion, but he soon gave up this view. Nor can he accept the explana- 
tion, suggested by the analogous phenomena in striped muscles, that it is due 
to extension and shortening (extension where the uterus meets with difficulty 
in emptying itself, shortening where it becomes emptied during a pain), 
though he is convinced that the contraction-curve is modified by the pains 
being effectual or not. After numerous laborious experiments, he has come 
to the opinion that the various contraction-curves are simply due to the fact 
that the whole uterine muscle does not contract simultaneously, but in a 
peristaltic manner. In addition to the peristalsis, the form and distribution 
of the muscular elements have some influence, though this is of secondary 
importance. In a cylindrical uterus the ascending a ad descending portions 
of the pressure-curve will be the same. But in a conical or funnel-shaped 
uterus the contraction-curve will first ascend rapidly and then slowly fall, 
since a higher internal pressure results when the upper than when the lower 
end contracts. The muscular tissue of the uterus affects the form of the 
muscle-curve according to the thickness of its several zones. When the 
thickest, and therefore most powerful zone, is above the middle of the uterus, 
as is generally the case, the greatest intrauterine pressure, and therefore the 
acme of the pain, will occur before its middle, the ascending limb being 
therefore the steepest, the opposite holding good in the rare cases where the 
thickest zone is in the lower portion. 

As regards the direction of the peristaltic movements, it runs in the human 
uterus, as in that of the lower animals, from the ends of the Fallopian tubes 
to the os uteri. 

Schatz is inclined to think that entire zones of the uterus are simultaneously 
at the same phase of contraction, so that peristalsis does not advance grad- 
ually, but by leaps. 

Quinine as an Oxytocic. 

In the Atlanta Medical and Surgical Journal for March, 1886, attention is 
drawn to the use of quinine as an oxytocic, by J. A. Coe and J. E. Allen. 
That quinine has no action on the pregnant or non-pregnant uterus in initiating 
contractions, is a fact which is fully borne out by the experience of all medi- 
cal men in malarial districts. On the other hand, when given in doses of 
gr. x and upward during labor, it is capable of exerting a stimulant action 



276 PKOGEESS OF MEDICAL SCIENCE. 

on the uterus. This action is probably the result of its effect upon the cord, 
quinine acting as a cerebro-spinal depressant. By lessening the abnormal 
sensibility of the inhibitory centres of the cord, it allows the normal reflexes 
to go on, and thus indirectly increases the action of the uterus. 

On the Possibility of Perceiving the Cardiac Impulse of the Intra- 
uterine FffiTUS WHEN THE LATTER IS EXTENDED. 

In Centralbl. f. Gyn. for Dec. 5, 1885, Fischel claims that he, together with 
Dr. Bayer, discovered the above phenomenon quite independently of Prof. 
Valenta (though he admits the claims of priority of the latter), and that 
while Valenta merely asserted that with very thin abdominal walls it is 
sometimes possible with a first face presentation (i. e., chin to the right) to 
feel the cardiac impulse, he (Fischel) showed that the phenomenon could be 
observed in all cases of extended attitude in the second position (chin to the 
left), also stating that he himself had in the latter actually observed it with 
vertex, brow, and face presentations. 

Fischel considers that, owing to the peculiar topographical relations, this 
phenomenon is most easily perceived in the second position, the first being 
very unfavorable for its recognition. In the latter it can only be done when 
the long diameter of the face is pretty nearly in the antero-posterior pelvic 
diameter, and when the thorax of the child lies close to the anterior wall of 
the uterus. Since at this time the face is generally already on the floor of 
the pelvis, the foetal cardiac region can be but little above the symphysis, where 
the bladder, generally more or less filled, is interposed between the uterus 
and abdominal wall, and must increase the difficulty of detecting this phe- 
nomenon, so that it is very rarely noticed in the first face position. 

Fischel, moreover, has observed it not merely where the abdominal walls 
were very lax and thin, and the uterine walls also very thin (as is said by 
Valenta to be necessary), but also in well-nourished women with moderately 
thick layers of fat, and without the uterus being very thin-walled; the phe- 
nomenon is further favored by rupture of the membranes having taken place, 
for so long as these are entire the foetal thoracic region is not always in close 
contact with the uterine wall. 

As an important etiological factor, he mentions that in all his cases the 
labors were somewhat delayed, and that the foetal cardiac region was placed 
below the "contraction-ring" in the stretched lower segment of the uterus. 
He has, moreover, seen it in a transverse position, especially in the right 
shoulder position, abdomen to the front, and in a first pelvic end presentation 
associated with an extended attitude. In conclusion, Fischel claims that his 
observations as regards this phenomenon are much more complete and much 
more satisfactory as regards the genetic relations than those of Prof. Valenta. 

Some Recent Considerations on the Prefoztal Dilatation of the 
vulva, accompanied by a study on the formation and rupture of 
the Sac of the Liquor Amnii. 

Dr. Leon Dumas, in Annates de Gynecologie for Sept., Oct., and Nov. 1885, 
referring to an article published two years ago by himself under the title of 
"Prefcetal Dilatation of the Vulva," acknowledges that he has since that 



MIDWIFEEY. 277 

time been on the watch for an opportunity of again bringing the subject be- 
fore the profession ; this opportunity, he thinks, he has found in the publi- 
cation by Dr. Byford, of Chicago, of a paper entitled "Functions of the 
Membranes in Labor." The author allows that Dr. Byford comes to the 
same theoretical conclusions as those from which he himself starts, but diners 
entirely as regards the application of those views. Before going into a dis- 
cussion of the merits of his own views, he puts Dr. Byford's opinions briefly 
before his readers. 

Resume, of Dr. By ford's ideas. Briefly considered, these ideas are: (1) that 
just as the bag of membranes dilates the cervix uteri, so they should be allowed 
to distend the vulva; and (2) that every effort should be made to preserve 
the membranes intact until the head passes the perineum ; with this view the 
woman is directed to keep quiet, resting on her back; she is not to strain, and 
violence of pain is to be kept in check by opiates or chloroform. The advan- 
tages claimed by Dr. Byford for his method, are safety for the perineum, 
absence of tendency to prolapse on the part of the umbilical cord, and pos- 
sibility of correcting malposition of the head, even when the latter is engaged 
in the pelvic cavity ; should the amniotic sac rupture prematurely, Dr. Byford 
resorts to digital pressure or inflated air-bags to effect the dilatation of the 
vulva. 

Examination of the method proposed by Dr. Byford. Granted that the prin- 
ciple recognized by the American accoucheur is correct, the question of real 
importance becomes this : " Is it possible, in the majority of cases, to reckon 
on the bag of waters for the dilatation of the lower orifice of the vagina?" 
The author of this paper answers unhesitatingly in the negative, and claims 
that his reasons for so doing are based on a strict observance of nature's 
usual method ; certainly in most cases the membranes rupture as soon as the 
cervix is completely dilated, and not before. Dr. Eibemont has shown ex- 
perimentally that a great difference frequently exists in the toughness of the 
membranes, and that, caiteris paribus, the time of spontaneous rupture largely 
depends on this. Dr. Byford considers that allowing women to walk about 
during the first stages of labor is distinctly injurious, and favors early rupture 
of the membranes. Dr. Dumas entirely disagrees on this point, and considers 
that in many cases of uterine obliquity the very reverse is the truth. It may 
be then taken for granted that, as a rule, under normal conditions the waters 
break away under the influence of uterine contractions soon after the dilata- 
tion of the cervix is complete. Dr. Byford quotes those cases in which the 
foetus is born with a caul in support of his views ; he maintains, too, that the 
membranes becoming detached from the lower segment of the uterus are 
driven through the dilated cervix with the head, until they come into contact 
with the vaginal walls, as yet undilated ; from these latter they receive support 
till the vulva is reached. The author rebuts the above assertion by drawing 
attention to the lax state of the vagina in the latter part of pregnancy, and 
the impossibility of any support from the vagina when the uterus is exerting 
a force of ten to eleven kilogrammes above. Dr. Dumas goes still further, 
and seeks to demonstrate the utter impracticability of preserving the bag of 
waters intact until the vulva is reached under ordinary conditions, whatever 
precautions may be taken. 

The behavior of the membranes during the obliteration and dilatation of the 



278 PROGRESS OF MEDICAL SCIENCE. 

cervix. The question is put by Dr. Byford, "What is there to hinder the 
membranes from arriving at the vulva?" To this the author replies, "the 
sudden distention to which they must yield when the neck of the womb is 
completely or almost completely dilated." According to Ribemont, two ele- 
ments are possessed by the membranes : (1) that of resistance, and (2) that of 
extensibility ; and, according to Dr. Dumas, the last named is the most im- 
portant. Remembering how the limit of extensibility depends on the force 
not being applied too suddenly, and pointing out that at the moment of com- 
plete dilatation of the cervix, and at that moment only, the membranes are 
subjected to a sudden distention which did not exist before, the conclusion 
becomes inevitable that rupture of the membranes at that moment is inevitable? 
and under normal conditions will happen then and then only. After a brief 
review of Cazeaux's opinion, that the bulging of the bag of membranes is not 
due to an elongation of the membranous sac, but rather to a change of shape 
on the part of the ovum, attention is called to the fact that in the obliteration 
of the cervical canal and the dilatation of the os, considerable change is 
effected in the relations of the lowest part of the membranes. This lowest 
part of the ovum, which during pregnancy adhered to the lower uterine seg- 
ment, comes, at the onset of labor, into relation with the cervical wall. Two 
hypotheses only can explain this: (1) either the membranes have undergone 
an enormous distention at the level of the cervix, and have furnished a finger- 
like prolongation which has advanced as far as the os externum ; or (2) the 
membranes have become separated to a certain height from the lower segment 
of the body of the uterus, and so have come in contact with the wall of the 
obliterated cervix. Dr. Dumas pins his faith to the last of these two views, 
though he admits that the majority of authors differ from him. Two clinical 
facts may be quoted in support of the theory that separation of the membranes 
takes place: in inducing premature labor near the end of pregnancy by means 
of the passage of a flexible catheter, it is found that the instrument passes to 
a certain distance easily, but then meets with resistance, owing probably to 
its having reached the point where separation of the membranes from the 
uterine wall still remains to be accomplished; in the second place, at the 
onset of labor, or a few days previously, mucus streaked with blood is often 
discharged per vaginam, and it may reasonably be surmised that these blood 
streaks result from the rupture of small vessels during the separation of the 
membranes. An argument again might fairly be drawn from cases of placenta 
prsevia ; if the placenta in these instances so readily separates from the uterine 
wall, is it more difficult to believe that the lower part of the decidua may do 
the same? 

By the aid of diagrams the relation of the membranes to the lower uterine 
segment and cervical canal during obliteration and dilatation of the cervix is 
shown, and then the author propounds two alternatives — either there is separa- 
tion and a gliding movement on the part of the membranes, or else there 
is an enormous distention of the sac sufficient to allow of its reaching the os 
externum. Now by experiment it is possible to show that the membranes 
cannot support a pressure capable of bringing them by distention to the ex- 
ternal os without rupturing ; proof of this is given by the investigations of 
Matthews Duncan. The latter author has shown that the elasticity of the 
membranes seldom passes the limit of two and a half centimetres (one inch), 



MIDWIFEEY. 279 

and as an elongation of five centimetres (two inches) would be required if 
the distention theory was correct, it is evident that delivery could rarely take 
place without premature rupture of the membranes. It may be well here 
to notice two pieces of clinical evidence : If the lower extremity of the mem- 
branes really came lower down in consequence of their distention, their pro- 
gressive descent in the pelvis ought to be capable of being recognized, and 
again the measurement of the ovum from above downward ought to increase, 
and yet neither of these points is capable of demonstration. It is true that 
some authors claim a lengthening of the ovum to take place during labor, 
under the influence of what Schatz has termed the " force of restitution of the 
form of the uterus," but this at most amounts to only six millimetres (one- 
quarter inch), and can only take place when the pains are powerful, and 
quite different to those required for the obliteration of the cervix. Again, as 
regards the descent of the ovum into the pelvis, it is clear that when this 
exists it is due to the fact that the whole uterus has sunk in the pelvic cavity, 
and not to any individual lowering of the ovum ; the bag of waters, even 
during a pain, is seldom more than a few millimetres in advance of the head, 
and in the intervals lies unstretched and slightly wrinkled. If, then, the 
membranes cannot even stretch sufficiently to reach the os externum, they 
certainly will not reach the vulva and distend that, as Dr. Byford would 
demonstrate. By the aid of further diagrams, the author shows how, during 
the process of obliteration of the cervix and dilatation of the " os," the lower 
segment of the membranes comes in contact with correspondingly lower seg- 
ments of the utero-cervical canal, until at length dilatation is complete, and the 
projecting part of the sac of the membranes bulges down free into the vagina. 
The question might fairly be asked at this point, why, if the extensibility of 
the membranes can be altogether disregarded, the process of separation does 
not go on still upward, and affect all the rest of the membranes, placenta 
included. This is just the point which will be brought out on examining the 
action of the muscular wall of the uterus ; though the length of the cervix 
has been added to that of the body of the uterus, still the total length remains 
the same; or, in other words, the body of the womb has shortened up. Thus, 
during dilatation, as well as during obliteration of the cervix, the latter is 
drawn upon and elongated upward, while at the same time the body of the 
uterus becomes thicker and shorter. Two important clinical facts prove the 
above statements: in the first case, when the anterior lip has been caught 
between the advancing head and the symphysis, it is found on freeing the 
imprisoned lip that the whole cervix is rapidly drawn above the head, though 
the latter does not descend an iota; and, in the second place, where the head 
lies low in the pelvic cavity, resting on the perineum before dilatation is 
effected, the latter process is completed, and the cervix is drawn above the 
head without any further real descent of the vertex. From the consideration 
of the above description, it may be seen that it is not the ovum which sepa- 
rates itself from the uterine wall and glides toward the os externum, but the 
uterine wall which separates from the ovum in the course of retraction, and 
glides upward along the membranes dragging the cervix from below upward. 
The point where the process of separation ceases can scarcely be fixed with 
accuracy, but probably the pressure of the circumference of the foetal head on 
the external mouth of the uterus subjects the membranes to an amount of 



280 PROGRESS OF MEDICAL SCIENCE. 

distention which prevents further separation. The author does not deny that 
the membranes possess the power of extensibility to a small degree, but does 
not attach much importance to this feature in the progress of labor ; he calls 
attention to their permeability by liquids, and gives this as a safeguard against 
premature rupture with escape of the liquor amnii. 

Mechanism of the preservation and of the rupture of the bag of waters in nor- 
mal cases. From what has been already put forward, it will be evident that 
as soon as dilatation is complete, and the membranes have reached their limit 
of extensibility, viz., two and a half centimetres (one inch), rupture under 
normal conditions must follow. Attention is called to one additional point : 
owing to the close adaptation of the child's head to the lower uterine seg- 
ment, the pressure on the amniotic fluid lying between the vertex and the 
presenting membranes is not equal to that exercised on the bulk of water 
above, not, at all events, until dilatation is complete ; the pressure supported 
is the total uterine force, minus the resistance of the cervical tissues. By the 
above consideration it is evident that the chance of premature rupture is 
greatly lessened. 

Application of the foregoing theory. If the line of thought already pointed 
out is followed, there is no difficulty in seeing how, after the expulsion of the 
foetus, the membranes aud placenta will be separated in the same way by the 
contraction and retraction of the upper part of the uterus. Possibly in the 
light of this theory one of the determining causes of labor may be found, the 
separation of the membranes being produced in the first place by the uterus 
absorbing the cervix in order to make more room for the enlarging ovum, 
and then the contact of these membranes with the cervical surface setting up 
reflex stimulation. Retention or non-separation of a portion of the membranes 
in cases of hasty delivery would also be accounted for by the theory pro- 
pounded. One, however, of the most interesting applications is the bearing 
the theory has on the explanation of cases of " placenta previa." Without 
going over the whole ground, it will be seen at a glance that it accounts for 
all the phenomena observed, and satisfactorily bridges over the gaps so patent 
in the theories of other observers. There are a few facts which can, indeed, 
be scarcely explained apart from the theory now under discussion ; these may 
be briefly summarized : 

1. Analogy between the mode of evacuation of the uterus and certain 
other hollow organs. 

2. The apparent and real mechanism of the mechanical dilatation of the 
cervix. 

3. Cause of the form " en boudin," which the bag of waters presents at 
times. 

4. Premature rupture of the membranes. 

5. Rupture at a point high up in the uterine cavity. 

6. Rupture retarded. 

The author quotes the peristaltic action of the intestine, the mode of action 
of the pharynx in deglutition, and the method in which the segments of the 
mitral valve come together leaving the ventricle full of blood, as illustrations 
of analogy. Regarding the second point, attention is drawn to the fact that the 
presenting bag of membranes is really a ''passive" dilating wedge, the cervix 
using it as a supporting point over which to withdraw, and not being actually 



MIDWIFERY. 281 

pressed open by the active incursion of the former. The presentation " en 
boudin" is doubtless due sometimes to the unusual elasticity of the mem- 
branes; but, as a general rule, it is caused by the foetal part remaining more or 
less unduly elevated above the bag of waters. As a result of the membranes 
separating to an undue height, the influence of the presenting foetal part on 
the form of the sac of waters is lost, and the membranes are able to assume 
the glove-finger shape. In consequence of this, the tension is low in the 
presenting sac, and dilatation progresses but slowly. Premature rupture can 
usually be explained, disregarding cases of extreme thinness or delicacy of 
the membranes, by the existence of conditions which at an early stage allow 
of the whole intrauterine pressure being brought to bear on the presenting 
bag of membranes. Such are cases of contracted pelvis, face, shoulder, and 
breech presentations. Rupture at an elevated point in the uterus is probably 
to be accounted for by the membranes having a firmer attachment at one 
part than another, since, owing to this, separation takes place in a less regular 
method, and unequal dragging causes rupture. Other causes, such as blows, 
shocks, or irregularly violent pains, are possible. Reasons for delayed rupture 
can easily be formulated, if we study the mechanism in the cases already 
considered. 

Refutation of Dr. ByforoVs views. Superiority and new advantages of prefcetal 
dilatation of the vulva. The advantages which Dr. Byford claims for his 
method are, that it enables a faulty position to be redressed when the head is 
in the pelvis ; and, secondly, that it affords a safeguard against prolapse of 
the cord. It is difficult to see how either of these advantages is secured by 
retaining the bag of membranes intact till the vulva is reached. As a matter 
of fact, Dr. Byford's method may become a source of real injury to the 
mother, first, by the tedious labor it entails, and, secondly, by encouraging 
the separation of the membranes to proceed so far up the uterus that the 
placenta may become detached and the foetus thereby asphyxiated. The 
elastic, dilating bag with which Dr. Byford proposes to dilate the vulvo- 
vaginal orifice in case of early rupture of the membrane is also useless, for if 
tightly distended it causes exquisite pain ; and if only partially filled, it is 
driven out by the pressure from above. Equally faulty is his idea of passing 
two or three fingers into the vagina and pushing back the perineum during 
the pains. In concluding, two special points in his own method of treatment 
are dwelt upon by the author. The vulvo-vaginal orifice having been ren- 
dered yielding and dilated by digital manipulations, a moment is chosen 
when a strong pain is over, and then the patient being directed to avoid 
straining, the right hand being laid flat on the posterior commissure of the 
vulva and the anterior part of the perineum, these latter parts are pushed 
backward over the foetal head, which at the same time is supported and kept 
in its present position. The chin once reached by the above method is disen- 
gaged by pressing on it with the finger-tips across the perineum and from 
behind forward. Regarding the most suitable time for executing this move- 
ment, advantage should be taken of the moment when the fingers, which 
execute the prefcetal dilatation, feel the frontal bosses at the fourchette or the 
line of the hair on the child's forehead. In all cases the manoeuvre is to be 
carried out in the interval between two pains. The second point that is 
dwelt upon is the necessity that exists for careful observation lest the head 



282 PKOGEESS OF MEDICAL SCIENCE. 

should be incompletely flexed when presenting at the lower outlet; inatten- 
tion to this point may not only mar the success of the author's manoeuvre, 
but lead to ruptures of the vestibule and adjoining tissues. Dr. Dumas con- 
cludes by reference to observations taken by M. Passarini, confirming the 
success of his method; and also points out how greatly the period of expul- 
sion is shortened. In a short note appended to his paper, he condemns the 
use of all instruments (including a special speculum invented by Prof. Carlo 
Minati, of Pisa) for prefoetal dilatation, and claims for digital dilatation that 
it possesses the advantages of delicacy of manipulation and accuracy of 
information such as may be gained in no other way. 

Dropsy and Albuminuria in Pregnancy. 

Leyden contributes an article on the above subject to the Deutsche med. 
Woch. for March 4, 1886. He defines the nephritis of pregnancy as a disease 
associated with pregnancy, and one which is liable at any time to induce 
attacks of eclampsia. It commences during the second half of gestation with 
albuminuria and dropsy, both of which increase till the onset of labor, and 
then rapidly subside. By these characters it may be diagnosed from other 
renal diseases accompanying pregnancy. 

As regards the anatomical characters in the kidneys, there is much differ- 
ence of opinion amongst various authors. Leyden in three cases has found 
large, pale kidneys with a good deal of fat in the tubules, and believes that 
both the symptoms and post-mortem appearances are best explained by a 
prolonged state of arterial anaemia. 

The prognosis is generally thought to be good so long as no eclampsia 
supervenes. Leyden, however, has seen cases which ended fatally apart from 
any symptoms of eclampsia. Moreover, in several cases under his care, a 
chronic disease of the kidneys ensued, which generally took the form of renal 
atrophy. 

The Advisability of Inducing Abortion in Cases of so-called 
Uncontrollable Vomiting of Pregnancy. 

This subject was brought before the Obstetric Section of the Suffolk District 
Medical Society, Dec. 16, 1885 (Boston Medical and Surgical Journal for Feb. 
11, 1886, p. 121). Dr. 0. W. Roe related a case in which the question of 
inducing abortion arose. The patient was nearly three months advanced in 
pregnancy. She had taken no nourishment by the mouth for nearly five 
weeks, as even the mention of food would excite vomiting. Nausea was con- 
stant and intense ; vomiting occurred every two or three hours. Any sudden 
noise or sudden appearance of any one by the bedside, would excite vomiting. 
Though the enemata were well retained, the patient had become greatly 
emaciated, and too weak to move herself in bed. There was excessive ptyal- 
ism, especially at night ; at other times thirst was intense, tongue parched and 
dry, breath very offensive, and along the course of the oesophagus and at the 
epigastrium there was marked tenderness. Pulse 116, temperature 97°. The 
cervix was firm and unyielding; the os only slightly patulous. The uterus 
was morbidly ante verted, the fundus resting against the rami of the pubes, 
and, on examination, could be raised up out of the cavity of the pelvis, but 



MIDWIFERY. 283 

fell back again directly upon the removal of the finger. In the preceding 
pregnancy it is stated that " the nausea and vomiting, though much less severe, 
yielded suddenly and completely at the beginning of the fourth month after 
the attending physician had, on vaginal examination, by chance raised the 
uterus high out of the cavity of the pelvis." In the present case the exciting 
cause of the vomiting was attributed by the author entirely to the displace- 
ment of the uterus, and consequent pressure upon the pelvic parts. As soon 
as the pressure was permanently removed, by raising the body of the uterus 
out of the pelvic cavity, the vomiting and nausea instantly ceased. As soon 
as the vaginal tampons were at all displaced, so as to allow the body to pro- 
lapse or antevert, the nausea and vomiting would instantly return. 

Dr. Roe advocates the induction of abortion in any case in which rectal 
alimentation becomes impracticable, and in which bromide and chloral fail 
to check the vomiting, provided no relief follow the rectification of any mal- 
position of the uterus which may be present. In support of this procedure, 
he brings forward two series of cases observed by various authors — 28 in which 
artificial abortion was not induced, and 20 which were terminated by artificial 
abortion. In the former the recoveries and deaths were equally balanced. 
In the latter series 16 recoveries occurred as against 4 deaths. 

From the generally accepted fact that the so-called uncontrollable vomiting 
of pregnancy may be due to one or more causes acting singly or in conjunction 
one with another, and consequently calling for treatment, as disease or the 
pathological conditions on which it depends, it is much to be regretted that 
no mention is made of such highly important associated conditions as alcohol- 
ism, constipation, albuminuria, jaundice, and neurosis, a due appreciation of 
which is absolutely necessary before arriving at the necessity for the induction 
of abortion, as a means of bringing not only the vomiting but also the preg- 
nancy to an abrupt termination. The absence of a careful post-mortem report 
is likewise to be deplored in those cases which terminated fatally. The sub- 
ject was lately somewhat fully discussed in the Obstetrical Society of London 
{Obstetrical Transactions, vol. xxvi. for 1884, pp. 273 et seq.), and our author 
might with advantage study the literature of the subject, which is large. 

Extrauterine Gestation ; Death from Rupture. 

At a meeting of the Brooklyn Pathological Society, held in October (New 
York Medical Journal, January 23, 1886), a specimen of tubo-uterine gestation 
was exhibited, in which death had resulted from rupture of the sac. The 
fcetus, estimated at two to three months, had escaped with a quantity of blood 
into the abdominal cavity. A corpus luteum was found in the right ovary, 
and gestation had taken place in the uterine extremity of the right tube. 
The inner (uterine) third of the wall of the sac was formed by the muscular 
wall of the uterus, the remainder by the dilated tube. The sac contained 
part of the membranes, some clotted blood, and a mass of chorionic villi. 
The rest of the membranes had protruded through a circular opening in the 
postero-external aspect of the sac. This opening was in great part surrounded 
by inverted edges, which were partially adherent to the protruded membranes. 
The foetus had escaped through a rent at the outer aspect of the projecting 
membranes. The placenta was found attached high on the anterior uterine 



284 PROGRESS OF MEDICAL SCIENCE. 

wall, adjoining the opening between the uterine cavity and the sac. The 
membranes separated from it during extrusion from the sac. The mucous 
membrane of the cavity of the body of the uterus was thick, soft, and exfoli- 
ating. That of the cervix was congested, slightly thickened, but firmly 
adherent, and did not present the common arbor vitae appearance. 

A Case of Extrauterine Pregnancy. 

Dr. G. B. Bobertson reports in the British Medical Journal for February 
13, 1886, the following case: Lavinia B., a?t. thirty-three, was the mother of 
two children, aged four and two years. On May 22, 1885, ten weeks after the 
last period, she was suddenly seized with severe pains in the lower part of 
the abdomen, followed by faintness and sickness. A second attack, more 
severe than the first, occurred a week later, but passed off in the course of a 
few days, and was followed by some distention and tenderness in the lower 
part of the abdomen. The uterus was somewhat enlarged, and on the left 
side, but quite separate from it, was found a tumor about the size and shape 
of an orange, "neither so smooth nor so hard as a fibroid, yielding to the 
pressure of the finger, but giving no sensation of fluidity." It seemed to be 
firmly fixed in the pelvis. During the attack it was tender on pressure. 
Throughout June and July the patient suffered frequently from colicky pains, 
and had two more attacks like the preceding, but less severe. On June 24, 
and again on the 30th, she had a show, but no membrane or solid substance 
was expelled. Meanwhile the tumor had been increasing steadily in size. 
Toward the end of July, however, it began to get smaller. On August 12, 
symptoms of intestinal obstruction set in, and stercoraceous vomiting followed. 
The tumor was quite immovable, and bulged more prominently into the pelvis, 
obstructing the large bowel. Enemata were ineffective. On August 14 the 
patient was chloroformed and placed in the lithotomy position. The tumor 
was reached by a left lateral incision through the perineum, and explored 
with the finger. It is noted that the opening was both contractile and 
dilatable. A portion of the placenta was recognized. The foetus, apparently 
of about four months gestation, shrunken and macerated, was then found and 
removed by gentle traction on a foot. During the operation, well-marked 
labor pains were observed. The umbilical cord was divided and replaced in 
the sac after the removal of a small quantity of old blood-clot. Shortly after 
the introduction of a double drainage tube, alarming hemorrhage set in, 
probably from partial detachment of the placenta, which impinged on the 
opening. It was, however, soon controlled by hot water irrigation. The 
wound was packed with cotton, soaked in sublimate solution. On the follow- 
ing day the bowels acted freely ; all symptoms of obstruction had disappeared. 
The sac was frequently irrigated with warm water. On August 22 the pla- 
centa was detached with the finger, and removed piecemeal. It was consid- 
erably larger than is usual in a four months' pregnancy. The sac was washed 
out with carbolic lotion (1 in 40). Recovery was uninterrupted. The tem- 
perature remained normal. On September 1 the patient was allowed to sit 
up in bed, and on September 6 was down stairs attending to her household 
duties. The wound speedily healed. On October 28 the patient had men- 
struated a fortnight previously in the usual way. There was some rigidity in 
the left fornix, and a cord-like hardness could be felt along the left vaginal 



MIDWIFEKY. 285 

wall in the track of the wound. The uterus occupied the normal position, 
was movable, and in other respects free from disorder. 

On the Value of Braxton Hicks's Method of Combined Version 
in Cases of Induced Premature Labor. 

Fehling, in the Centralbl f. Gyn. for March 6, 1886, discusses the value of 
the above treatment in the troublesome cases in which premature labor has been 
induced, but in which pains are very feeble and inefficient. In many of these 
cases the child dies through want of oxygen, and extraction has to be done 
under circumstances rendered much more difficult by the delay. To avoid 
this, Fehling has adopted the following plan : After inducing premature labor, 
and encouraging the onset of pains by the usual methods, he turns the child 
by Braxton Hicks's combined internal and external version, with the object 
of bringing down a leg and thus obtaining a control over the extraction, 
should the latter become necessary. When version has thus been performed, 
and the breech brought down into the pelvis, pains frequently come on and 
labor advances rapidly ; but if not, or if the heart sounds of the foetus indicate 
that its life is endangered, extraction must be proceeded with. 

Fehling thinks this procedure especially well suited for multiparae, in whom 
uterine inertia under these circumstances is common. But in primiparse and 
multiparae, in whom strong pains come on and soon fix the presenting part in 
the brim, it is not so appropriate. Extraction should not follow immediately 
on version ; it should be delayed till definite indications arise. 

Splitting of the whole Urethra during Labor. 

Krukenberg relates an instance of the condition named above in the 
Centralbl. f. Gyn. for November 28, 1885. 

Mrs. W., set. twenty-eight, confined four times. First child (breech pres- 
entation) was born dead ; in the second labor a living child was delivered 
with forceps; in the third a living child was born spontaneously. Post- 
partum periods normal. During the last confinement (May, 1885), the 
midwife, after rupture of the membranes, made the woman stand between 
two chairs, lean forward and rest her arms on the backs of the chairs. In 
this position the child was born spontaneously and alive. The labor was 
immediately followed by severe hemorrhage, which the midwife stopped by 
pressing her hand against the vulva. Since then the woman has had total 
incontinence of urine. 

She applied for admission to the hospital on July 3, 1885, requesting to be 
operated on. Pelvis normal. The posterior wall of the urethra was found 
to be split throughout its whole length by a median longitudinal fissure, 
the smooth and thin edges of which lay in contact, so that no gap existed. 
Apart from a small, old cicatrix due to a perineal tear, no scars were visible 
either at the anterior or posterior vaginal wall. The mucous membrane of the 
urethra appeared normal. By gently pressing in the finger, the bladder was 
reached and found to be only about two and a half centimetres long, and to 
present trabeculse but no diverticula. Uterus retroverted, not enlarged, 
movable ; parametria free. 

The operation needed was very simple : the edges of the tear were refreshed 



286 PROGRESS OF MEDICAL SCIENCE. 

and united by a suture. During the first eight days after the operation the 
bladder was drained according to Fritsch's method; the wound healed by 
first intention without any rise of temperature. From that time the patient 
was able to hold her water completely, though at first obliged (without any 
evidence of cystitis) to pass it every five minutes. Inasmuch as the bladder 
even artificially could only be filled to a very slight extent, the frequent mic- 
turition clearly depended not merely on the weakness of the sphincter, but 
on the slight power of distensibility possessed by the bladder. Krukenberg 
attempted to increase its capacity by washing out the cavity regularly, but on 
the 27th of July the patient left, satisfied with the improvement. At that 
time she made water about every twenty minutes. 

Krukenberg states that this form of splitting is extremely rare, and unhap- 
pily, for want of details, he cannot say whether it was due to an abnormal 
position of the head, as occurred in a case published by Werth (Arck.f. Gyn., 
xvi. p. 126), but he considers that in all probability the posterior urethral 
wall in his patient was unusually delicate, which may have been due to a 
slight degree of hypospadias. 

Rupture of the Uterus. 

This case [Lancet, February 6, 1886, p. 268) formed the subject of a coroner's 
inquiry at Brighouse, in Yorkshire. The midwife in attendance found that 
the membranes had ruptured, and recognized an unusual presentation. Ac- 
cording to her story, the patient was seized with a " sick fit," from which she 
never rallied. Whether forcible traction was made on the leg of the foetus 
before or after this event is a point which is open to doubt. At any rate, the 
midwife allowed more than an hour to elapse before calling in medical aid. 
On reaching the house, Dr. Bond, the physician consulted, found the patient 
dead. At the post-mortem examination a rent twelve inches long was found 
in the uterus on the left side toward the front, and in that portion of the 
uterine wall which had impinged on the pubic bones there were extensive 
bruises extending through its whole thickness. It became a matter for con- 
sideration whether these bruises could have been produced by the uterus 
being driven against the pelvis by its own contraction, or whether it was not 
more likely that they were caused by forcible pulling on the leg of the foetus. 

A Case of Cesarean Section, with Remarks on the Use of 
Silver Sutures. 

Schauta, in the Wien. med. Woch. for Jan. 9, 1886, relates a successful case 
of the above, in which mother and child were saved, and discusses the value 
of silver sutures for sewing up the uterus. The main features of the opera- 
tion were the following: 

J. R., set. twenty-two, pelvis generally contracted, rickety, with a conjugate 
of six and a half centimetres (two and a half inches). The antiseptic system 
was carried out rigorously, and for eight days previous to the operation the 
air of the operating theatre was kept disinfected by a steam spray, consisting 
of a solution of corrosive sublimate (1 : 1000). The operation was performed 
as soon as the cervix had begun to dilate, and strong pains had set in. The 
abdominal incision measured eighteen centimetres (seven inches), and that 



MIDWIFERY. 287 

into the uterus nearly as much. The child was extracted without difficulty, 
nor did much hemorrhage follow the removal of the placenta and foetal 
membranes. An elastic band was tied round the cervix uteri at this stage, 
so as to check all bleeding, while the sutures were applied, and the cavity of 
the uterus washed out with a 1 : 2000 solution of corrosive sublimate. 

Schauta used silver sutures for closing the uterine wound, these being 
inserted at intervals of about two centimetres (eight-tenths inch), and made to 
pass right through the uterine wall, though leaving the decidua free. No 
special treatment of the peritoneal lining was adopted, except that when the 
eight silver sutures which passed through the entire uterine wall had been 
dealt with by simply twisting them, twenty-nine sutures of the finest silk 
were used for bringing together the edges of the peritoneum. 

When all these sutures had been inserted, the elastic band was removed 
from the cervix, and on slight bleeding showing itself between the edges of 
the wound, two more silver and five more silk sutures were added, ergotine 
being injected subcutaneously. 

The patient did exceedingly well ; her pulse never exceeded 120, and the 
highest temperature recorded was 38.9° C. (102° F.). Between six and seven 
weeks after the operation she was discharged well, and wrote afterward that 
menstruation returned in the natural way, and that her general health was 
excellent. 

Schauta points out that the recent conservative Caesarean sections have 
been very successful (ten recoveries out of fourteen cases), and he asks why 
they have been so much more successful than such operations were formerly. 
The antiseptic system rigorously followed has had, in his opinion, a large 
share in producing the result; yet even antiseptics cannot avert all the 
dangers associated with the operation, some of which dangers directly affect 
the peritoneum, while others are associated with septic lochial secretions, such 
as are discharged from the inner surface of the uterus, even in a normal 
puerperium. Schauta believes that it is only by accurately closing the 
uterine incision on the peritoneal side on the one hand, and on the side of 
the mucous membrane and its secretions on the other, and keeping the cut 
surfaces of the uterus in contact, that the dangers can be avoided. 

A study of numerous cases of Cesarean section in which the uterus has 
been sewn up has convinced Schauta that these conditions are only satisfied 
by silver sutures ; that, next to the antiseptic system, it is the use of this 
kind of suture that has caused the recent diminution in mortality. This, and 
not a resection of the muscular tissue, or careful manipulation of the serous 
membrane, is the secret of success. 

Amongst the most recent operations, Schauta finds eight in which silver 
and six in which silk sutures were used. Every one of the former recovered ; 
while of the six latter, four died; results which show how much more suc- 
cessful are cases treated with silver. 

Schauta next deals with the question as to how far resection of the muscu- 
lar tissue and the various ways of treating the peritoneum contribute to the 
success of Csesarean sections. He concludes that they have little influence, 
one way or the other; of far greater importance is the use of silver wire, 
instead of silk. 

In trying to explain why silver sutures are so preferable, Schauta finds that 



288 PROGRESS OF MEDICAL SCIENCE. 

the former keep the two sides of the uterine incision firmly and securely 
together, while silk tends to cut its way through the tissues. Moreover, the 
silk suture constricts the tissue it encloses, very much in the way that an 
elastic ligature would do, and it is well known how much traction is required 
to bring the two sides together ; while the silk cord passing from one side to 
the other invariably makes a more or less deep furrow, showing a considerable 
pressure on the enclosed tissues. Later on, the silk suture becomes softened, 
and it is then inefficient for its purpose. The action of a silver suture is veiy 
different. The two sides of the wound are held together with much less trac- 
tion; the included tissues are less compressed; and, instead of the furrow 
mentioned above, the wire forms a gentle curve. 

In conclusion, Schauta urges the use of the silver suture in all cases of 
conservative Csesarean operation. 

Unsuccessful Case of Cesarean Section after the Method of 
Sanger and Leopold. 

Munster, in the Centralblf. Oyn. for Feb. 6, 1886, relates an unsuccessful 
case of Csesarean section performed after the Sanger-Leopold method. The 
operation was rendered necessary by a tumor which filled up the posterior 
half of the small pelvis, and the woman had been in labor for more than 
three days before applying for help. The first steps in the operation pre- 
sented no special features. After removing the child with its placenta and 
membranes, Munster washed out the cavity of the uterus with a five per cent, 
carbolic lotion, and detached the serous lining from its subjacent tissue for a 
distance of one centimetre (four-tenths inch) along the entire length of the 
uterine wound, the two bands of peritoneum thus freed being reflected with 
forceps. A wedge-shaped margin (with its point toward the uterine cavity) of 
the muscular tissue was now cut away with a scalpel from both sides of the 
entire incision, after which the two flaps of serosa were so folded and brought 
together as to lie one against the other for the whole length of the wound. 
Ten deep sutures were passed through the whole muscular wall of the uterus, 
and then fifteen less deep or else superficial ones were inserted so as to bring 
the two layers of serosa accurately together. Carbolized silk was used for the 
sutures. The child was in a state of asphyxia when extracted, and could 
not be restored. The mother died four days after the operation. Post- 
mortem, both abdominal and uterine wounds were found well united, the 
sutures showing no signs of cutting their way out. The two strips of serosa 
were in good apposition. 

Munster attributes the fatal issue to the fact that the Csesarean section was 
postponed until the woman had been in labor for more than three days, that 
some hours had passed since the liquor amnii had been discharged, and that 
endometritis had already set in. The operation was done too late to be 
successful. 

Porro's Operation; Survival of Mother and Child. 

This operation was successfully performed in the Gynecological Clinique 
of Pavia, by Dr. Guzzoni degli Ancarani [Lancet, February 6, 1886). The 
patient was admitted at the eighth month of her seventh pregnancy, on June 



MIDWIFERY. 289 

10, 1884. She had suffered much from rickets in infancy. Her second preg- 
nancy ended in abortion at three months, the first resulted in a living child 
at seven months, and the fourth in twins at the same period of gestation ; 
the third, fifth, and sixth in living children at term. Five years had elapsed 
since the last confinement. The pelvis was so much deformed that the lower 
outlet barely admitted the examining finger. Labor pains commenced at 
1 P. M. on July 22d. An incision eight inches long was made in the middle 
line, the uterus was brought out through the wound, and an elastic tube 
applied around the cervico-uterine cone (sul conocervico-uterino). After 
the foetus had been extracted the elastic ligature was replaced by a wire one. 
Perchloride of iron was applied to the stump of the amputated uterus, and 
it was fixed with a strong needle passing below the metallic ligature. The 
wound was sutured with antiseptic silk, and styptic colloid applied to the 
edges. The operation, which was performed with strict antiseptic precau- 
tions, lasted a little over an hour. The child, a male, was living. All the 
sutures were removed on the seventh and eighth days. Convalescence was 
uneventful. The patient was in fairly good health a year afterward. 

When should the Umbilical Cord be Tied? 

The Wien. med. Woch., December 19, 1885, summarizes Engel's investiga- 
tions on this subject. Engel recommends late tying of the cord, for when 
this practice is followed the newborn child receives as much as a quarter, or 
even a third more blood than its body would otherwise contain. Moreover, it 
is quieter, does not begin to drink so soon, and is more sleepy. Engel also 
finds that the plan of ligaturing late greatly improves the prospects of life of 
the newborn child. 

Out of 90 cases of premature birth in which the cord was tied immedi- 
ately after delivery, 18.88 per cent, died during the first 10 days, while out 
of 74 similar births in which the cord was ligatured late, only 9.45 per cent, 
died. Syphilitic foetuses and those weighing more than 3 kilos (6.] pounds) 
were not counted. 

This transfusion of blood where late ligature is practised is not due to 
thoracic aspiration or to uterine contractions, but to the cardiac activity of 
the foetus and to the contractility of the umbilical vessels. When the cord 
gets quite cold the arteries in it, owing to their marked contractility, become 
greatly narrowed and prevent any blood continuing to flow out of the child, 
while the blood continues to enter the body of the child by means of the less 
contractile umbilical vein. 

The Etiology of Ischuria during the Post-partum Period, and 
after the eemoval or tapping of large abdominal tumors, with 
some remarks on micturition in general. 

Schwarz, in the Zeitsch.f. Geb. u. Gyn. for 1886, differs from most authors 
in his opinion regarding the causes of the ischuria seen in the conditions 
mentioned above. 

Olshausen, for instance, believes that the ischuria after parturition is due 
to urethral obstruction. He supposes that the urethra is elongated when 
the bladder and uterus rise up into the abdomen during pregnancy, and that 

NO. CLXXXIII — JULY, 1886. 19 



290 PROGRESS OF MEDICAL SCIENCE. 

when the organs return to their usual situation, a bend takes place in the 
urethra which causes sufficient obstruction to bring on retention. 

Schroder, on the other hand, supposes these cases of retention to be due to 
the capacity of the bladder having been increased during the growth of the 
pregnant uterus, or other tumor, as the case may be, which increased capacity 
enables the urine to be retained for longer periods than before, and gives rise 
to a pseudo-ischuria. 

Schwarz believes there is a further cause at work which may explain the 
inability to micturate which undoubtedly exists, as well as the diminished 
desire to make water. This he finds in the fall of the intra-abdominal pres- 
sure which must accompany the termination of labor, or the surgical removal 
of large intra-abdominal masses, a fall which lasts for a considerable time if 
the horizontal dorsal posture is maintained. 

As regards the mechanism of micturition in general, Schwarz arrives at 
conclusions which are at variance with those usually accepted. According to 
the latter, urine is expelled from the bladder by the active voluntary or reflex 
contraction of its muscular walls, the cooperation of the intra-abdominal pres- 
sure being unnecessary, or, at most, of secondary importance. Schwarz, on 
the contrary, holds that it is not by contraction of the muscular walls of the 
bladder that the urine is expelled, but by the action of the intra-abdominal 
pressure on the distended bladder. That pressure is increased when the ab- 
dominal muscles are thrown into action, and when certain postures — e. g., the 
erect — are assumed, and when that increased pressure is brought to bear on 
the walls of the bladder, urine is expelled. He denies that the contractions 
of the muscular walls of the bladder are under the control of the will, and 
even when they contract in a reflex manner, as when a few drops of urine 
have escaped from the neck of the bladder, they are unable to expel the whole 
or even a large part of the urine. 

The sphincter at the neck of the bladder, however, does seem under the 
control of the will, though it may also act in a reflex manner. Voluntary 
micturition, therefore, according to Schwarz, takes place as follows : When, 
under the influence of the will or in a reflex manner, the sphincter vesicae is 
relaxed, urine will flow out much as during catheterization, since the whole 
bladder, except its lower wall, is exposed to the intra-abdominal pressure. 
The greater this pressure, the greater the rapidity and force of the issuing 
stream. The walls of the bladder, however, remain quite lax, their retraction 
being a consequence, not a cause, of micturition. According to this view, the 
musculo-elastic walls of the bladder have merely the function of enabling the 
organ to undergo great distention, and again to contract after evacuation. 

If the intra-abdominal pressure acting upon the bladder is very slight, and 
for some reason or other cannot be increased, micturition becomes difficult. 
Such conditions are met with in women recently confined, or after laparoto- 
mies, tappings of the abdomen, etc. — the dorsal recumbent posture alone is 
sometimes sufficient. The ischuria seen in diseases and injuries of the central 
nervous system, according to this view, is due, not to paralysis of the detrusor 
urina3, but to an inability to open the sphincter and to raise the intra- 
abdominal pressure to a sufficiently high level. 

Schwarz then describes some manometric experiments which he made with 
the object of estimating the intra-abdominal pressure. He connected the 



MIDWIFERY. 291 

urethra with a manometer, and was able to show that the pressure in the 
abdominal cavity was much as if the latter had been filled with water — in 
other words, any part of the abdominal cavity is under a pressure which may 
be represented by a column of water of which the height corresponds to the 
vertical distance of that part to the point which is highest in the abdominal 
cavity. Hence it follows that the pressure will always be greatest at those 
parts of the abdominal cavity which lie lowest, and vice versa. 

Further corroboration of this view as to the influence of the intra-abdominal 
pressure on micturition is given by others. Thus Schultze states that in a 
living woman the bladder, when empty, does not assume a globular shape, but 
that the walls become applied to one another, the upper one sinking into the 
lower, so as to produce a goblet-shaped organ. This, according to Schwarz, 
shows that the bladder is not emptied by an active contraction of its walls, 
for, if it were, it would become more or less globular. Again, if during lapa- 
rotomy the distended bladder is emptied by a catheter, the vertex of the 
bladder can actually be seen to sink deeper and deeper, and at last rests in 
the lower infundibular half; no ball-like contraction takes place ; the parietes 
remain loose and can be stretched in any direction. Again, women with a 
vaginal cystocele are only able (unless the cystocele is replaceable) to empty 
that part of the bladder which is still in situ, since the prolapsed portion is 
withdrawn from the influence of the intra-abdominal pressure. If the bladder 
becomes spherical on evacuation, the cystocele would become replaced and 
the whole of the urine would be expelled. But Schwarz finds the strongest 
evidence for his views in the following experiment : Two water manometers 
are used, one communicating with the moderately filled bladder, the other 
with the rectum. The tube j)assing to the rectum must be inserted at least as 
far as the descending colon, the intestine having been previously emptied of 
hard feces and moderately distended with water. When the patient is 
at perfect rest, whether erect, sitting, or lying, both manometers will stand 
at the same height ; but if he is now told to attempt to make water, two things 
may be noticed : first, that if a somewhat small catheter had been used to 
connect the bladder with its manometer, some drops of urine will escape by 
the side of the catheter, showing that the sphincter vesicas has relaxed; 
secondly, that the two manometers will be seen to rise to an equal height. 
Schwarz argues that if the efforts at evacuation caused an active contraction 
of the walls of the bladder, the manometer connected with it would indicate 
a greater pressure than that connected with the rectum, while, as a matter of 
fact, they remain at the same level, both during and apart from straining 
efforts. 

Ischuria, therefore, in the conditions under discussion, may be due to a 
deficiency in the intra-abdominal pressure which is necessary to expel urine. 

The Temperature of the Mammary Gland during the Puerperium. 

The Centralbl. f. Gyn. for January 16, 1886, gives an abstract of investiga- 
tions by Negri on the above. A surface thermometer was laid on one breast 
at the same time that an ordinary maximum thermometer was lying in the 
corresponding axilla. Negri found the temperature of the mammary gland 
to be higher post-partum than in pregnancy or the non-gravid state, though 



292 PROGKESS OF MEDICAL SCIENCE. 

never higher than that of the axilla, and only in exceptional cases as high ; 
the usual limits met with were 34° C. (93° F.) and 37° C. (98.5° F.), and only 
in rare cases was the latter exceeded. The more abundant the lacteal secre- 
tion, the higher the temperature, a persistently high temperature indicating 
a copious milk supply. 

The Prophylaxis of Pendulous Abdomen in Women. 

Czeeny, in Centralbl. f. Gyn. for 1886, No. 3, compares the tense and elastic 
condition of the abdominal walls of many English multipara? with the pen- 
dulous abdomen of Germans, and ascribes it to the fact that, at any rate in 
the upper classes in England, it is the custom for the accoucheur immediately 
after the completion of labor to apply a broad binder firmly to the abdomen 
of the parturient woman, which binder is generally worn for eight days. 
Czerny thinks it possible that such a binder applied at a time when important 
plastic and nutritive changes are taking place, may have a considerable influ- 
ence in restoring the tense and elastic condition of the abdominal walls which 
existed previous to pregnancy. There is some reason for supposing that it 
was formerly the custom in Germany to apply such a binder, but now it has 
fallen almost entirely into disuse. Czerny recommends that accoucheurs and 
midwives be taught immediately on the conclusion of labor to apply a broad 
binder round the lower abdomen, as a prophylactic measure against " pen- 
dulous abdomen." 

The Medico-legal Importance of Hematoma of the Sterno-mastoid 
in Newborn Children. 

KtJSTNER, in Centralbl. f. Gyn., No. 9, 1886, discusses the mode of origin of 
harnatomata in the sterno-mastoid muscles of newborn children, and combats 
the view that they are always due to the muscles having been exposed to ex- 
cessive traction. He relates a case of labor with breech presentation, in which 
no assistance of any kind was afforded — even the usual plan of supporting the 
trunk during the delivery of the head was not adopted — and yet a hsematonia 
appeared in the left sterno-mastoid. Kiistner infers that these swellings may 
occur even when a labor runs a perfectly natural course. 

Kiistner also records some experiments made on stillborn foetuses in which 
a row of pegs was inserted into the sterno-mastoid, and the neck stretched 
and rotated in various directions. He found that neither lateral flexion nor 
stretching of the neck had much effect in stretching the sterno-mastoid, and 
causing the pegs to separate ; but torsion of the neck did so readily, especially 
when the face was twisted toward the side under observation. Kiistner be- 
lieves that a similar movement during labor is the cause of hasmatomata, for 
torsions of the neck are well known to be of frequent occurrence, even in the 
ordinary mechanism of parturition. 

Kiistner admits that hsematomata are by no means uncommon in forceps 
extractions, but he believes that even in these cases they are mainly due to 
the twisting of the neck which is associated with such labors, though the 
pressure of the forceps may assist in the causation. 

Kiistner sums up his conclusions as follows : 

1. Hematoma of the sterno-mastoid is caused, not by stretching or exten- 
sion, but by twisting of the neck. 



GYNECOLOGY. 293 

2. Since the neck may be greatly twisted even in spontaneous delivery, a 
hsematoma may arise in simple cases both of vertex and of breech presentation. 

3. The occurrence of a haematoma therefore does not prove that criminal or 
instrumental violence has been resorted to. 



GYNECOLOGY. 



Shock, its Relation to Diseases of the Organs of Circulation 
in Abdominal Tumors. 

It has frequently been pointed out that women suffering from abdominal 
tumors are exposed to dangers (independent of those directly connected with 
the new growth) brought on by simultaneous changes in other organs ; and 
numerous deaths, especially after operations, have occurred in which the post- 
mortem examination revealed no other cause of death than those changes. 

In earlier times, when the term "shock" was a very comprehensive one, all 
these fatal cases were classed under it, but in 1883 Wernich drew attention to 
the fact that death is now much less frequently ascribed to shock, since 
pathology has made such rapid strides, and we now regularly look for definite 
anatomical changes in organs, especially in the heart. 

Indeed Wernich believes that in the future still fewer deaths will be ascribed 
simply to neuro-paralysis, and a review of numerous published cases, as well 
as those we have collected, confirm this belief. 

The perils referred to, which affect women suffering from large abdominal 
tumors are various, but mainly related to the organs of respiration and circu- 
lation. Partly on account of the growth of a very large tumor, partly on 
account of the prolonged interference with respiration and circulation, a sort 
of marasmus sets in, which is characterized by general emaciation, and the 
well-known facies ovarica. Moreover, a deterioration of individual organs 
takes place, especially of the heart, which, from being badly nourished, and 
called upon to do extra work, is often unable to meet the demands made 
upon it. 

Dangers of another kind are due to the fact that, in most of these tumors 
(especially in fibroids with very large veins), thrombi form which may be 
easily detached, and cause immediate death by pulmonary embolism, or, at 
least, lead to a condition of great danger. Schwarz has published two such 
fatal cases in which numerous emboli in both lungs were formed. 

Hofmeier (Zeitsch. filr Geb. und Gyn., xi. S. 366) recently had the same 
experience, except that the tumor was an ovarian one. For purposes of 
examination the patient was put under chloroform, and apparently she bore 
it well. But the next day, when she attempted to get up to have the bed 
made, intense dyspnoea set in, leading to immediate death. On the post- 
mortem table numerous pulmonary emboli were found. He had seen another 
case in which similar symptoms supervened, though happily they did not 
prove fatal. 

It appears that the formation of these dangerous thrombi is especially fre- 



294 PROGRESS OF MEDICAL SCIENCE. 

quent after removal of the ovaries. Dohrn, on the other hand, has published 
four cases of uterine fibroid in which death occurred, once before, three times 
after the operation ; in all of them pulmonary embolism was the cause. 

The heart, however, is the organ generally affected. Quite recently, Sanger 
and others have pointed out how seriously secondary changes in the muscular 
structure of the heart affect the prognosis of operations. Amongst the cases 
operated on by Schroder I have seen illustrations of this, and those especially 
are of interest in which death took place before the operation, inasmuch as 
all doubt as to the operation being the cause is excluded. 

The cardiac degenerations are not always due to pathological growths in 
the abdomen; they may be due to physiological changes; indeed, they are not 
uncommon accompaniments of pregnancy, and quite distinct from the brown 
cardiac atrophy so frequently met with in lying-in women who have died from 
septicaemia. Hofmeier has met with several such cases, of which one may 
serve as an illustration. 

•'Mrs. L., a robust, strong woman, confined June, 1884. Her pelvis was 
occupied by a tumor as large as a foetal head, which had to be pushed up into 
the great pelvis to allow the head to enter the brim. Labor went on naturally 
till near the end of the second stage, when the low forceps operation was used 
to extract the head, owing to the feebleness of the pains. After removal of 
the placenta, moderately free hemorrhage set in (due to an atonic condition 
of the uterus), which, however, was finally stopped. Two hours after she had 
a pulse of 80 to 150, and looked as if sinking ; nine hours after the end of 
labor she died in spite of the use of restoratives. Death was attributed to 
internal ^hemorrhage, but none could be found post-mortem. The tumor 
proved to be a pedunculated fibroid. The heart was not specially flabby, but 
it had undergone brown degeneration." 

In this, as in most other cases, death was most likely due to a combination 
of causes ; in other words, a hemorrhage which would not be dangerous in an 
otherwise healthy woman may be so, and even lead to a fatal termination 
when cardiac weakness due to brown degeneration of its muscular tissue is 
superadded. 

In all, Hofmeier has seen 19 cases of sudden unexpected death with patho- 
logical and physiological swellings of the abdomen, caused by, or at any rate 
accompanied by, secondary changes which, in part at least, were certainly 
brought on by the swellings. They consisted in one case of pulmonary embo- 
lism consequent on thrombosis in a tumor in the broad ligament, 3 (2 fibroids, 
1 ovarian cyst) due to extreme fatty degeneration of the cardiac muscle, 15 
(5 ovarian, 4 uterine fibroids, 1 of fibroma of the pelvic connective tissue, 5 
puerperal cases) due to the so-called brown atrophy of the heart's muscular 
tissue ; 5 died before operation, 9 after ; 5 after confinement. In reference to 
the question whether the cardiac complications are consequences of the new 
growths or accidental complications, he believes that a direct connection 
exists between the abdominal tumors and the cardiac changes. One other 
practical point remains ; can we make a sufficiently early diagnosis to avoid 
such catastrophies ? He believes that in cases of fatty degeneration we can; 
well-marked symptoms are present — weak cardiac action, general debility, 
shortness of breath, etc. It is otherwise, however, with brown atrophy ; no 
special clinical symptoms show themselves, and frequently there is nothing 



GYNECOLOGY. 295 

to call attention to the heart. It is not even always found in persons who 
have become feeble and cachectic, so that the practitioner may at any time 
be brought face to face with this disastrous complication. 

In the discussion which followed Hofmeier's paper, various speakers em- 
phasized the fact that these cases have nothing in common with shock in the 
proper acceptation of the word. 

Diabetes in Kelation to the Uterine Life, Menstruation, and 

Pregnancy. 

Dr. Lecorche, in a paper in the Annates de Gynecologie, for October, 1885, 
discusses this subject under the following heads : 

1. The influence of the uterine functions on the development of diabetes. 
Diabetes may occur in a woman at any period of life, but it seems to have a 
special tendency to do so in the premenstrual period, and after the meno- 
pause. To a certain extent the existence of the catamenia militates against 
the invasion of diabetes, and the earlier the menopause the greater the 
liability to early attacks of the disease. The gravity of the affection varies 
inversely with the age of the patient, and in attacks occurring during pre- 
menstrual life the ravages of diabetes are seen at their worst. 

2. Morbid states of the genital apparatus in diabetes. In a woman who is 
still regular, diabetes causes disturbances in the working of the utero-ovarian 
system, but before inquiring into these functional derangements, it will be 
well to study for a time the morbid anatomy and local lesions of the genital 
apparatus. 

a. Vulvar eczema. Of these lesions eczema is by far the most frequent; it 
was present in nearly a third of the cases observed, and in the majority of 
these cases the patient was of a somewhat advanced age. As a rule, vulvar 
eczema is regarded as an early manifestation of diabetes, but close investiga- 
tion will reveal that other symptoms of the disease have been present three 
or four years before the cutaneous affection ; it is true that this eczema is 
usually indicative of an intense form of the disease. In searching out the 
causes of this eczema, it is important to note the constitutional tendencies of 
the patient ; in many cases patches of eczema are found on other parts of 
the body, showing a leaning toward cutaneous disorders ; at the genital part, 
however, there can be no doubt that the eczema is due to the irritating action 
of the fermentation which occurs in the saccharine solution ; scrapings from 
the inflamed surface show the presence of spores and other evidences of 
fermentative action. The principal symptoms of diabetic vulvar eczema are 
three in number, viz., pruritus, the eruption itself, and a somewhat copious 
oozing. The first of these is the earliest symptom ; it often precedes the 
eruption for a considerable time, does much to break down the patient's 
health, resists treatment very obstinately, but undergoes remissions and 
exacerbations in proportion to the intensity of the glycosuria. The eczema 
starting from those parts most in contact with the urine — e. g., labia minora, 
spreads outward, and is often of a very severe type ; it is not infrequently 
complicated with vaginitis, granular erosion of the cervix, urethritis with 
frequent micturition, furuncles, and nervous affections, such as migraine, gas- 
tralgia, and various neuralgias, of which sciatica is the most notable. 



296 PROGRESS OF MEDICAL SCIENCE. 

b. Granular metritis; granulations and alterations of the cervix. Vulvar 
eczema and granular inflammation of the cervix often coexist ; in many cases 
it is evident that the inflammatory process has travelled along the vagina to 
the uterine mucous membranes, but in other cases no vulvar disease exists, 
and the uterine disease can only be ascribed to the morbid state of the blood, 
and the vicious influence thus exerted on nutrition. Confirmation of the 
above statement is given by the fact, that granulations of the pharynx or 
recurrent bronchitis not infrequently accompany the uterine disorder, thus 
signifying that in these cases the mucous tracts suffer, as the skin does in 
those where the vulvar eczema is the prominent feature. No definite relation 
between the severity of the glycosuria and the uterine disease has as yet been 
shown to exist; the granulations of the cervix may run on to extensive ulcera- 
tion, and the persistence of this latter, together with the failure of all treat- 
ment, will often give a clew to the existence of diabetes. 

c. Other uterine lesions. Diabetes is no bar to the existence of any lesion 
connected with the utero-ovarian system. Fungous metritis and attacks of 
ovaritis seem at times associated with the presence of glycosuria. 

3. Influence of diabetes on menstruation. When diabetes occurs in the 
course of the menstrual life, it rarely fails to exert an influence more or less 
marked on the uterine functions. At times the courses are simply irregular, 
at others attended with great pain, in some cases they cease for months, to 
reappear as the disease abates, or, again, the menopause may be induced pre- 
maturely. Occasionally in diabetic women, metrorrhagia is observed, but in 
such cases some marked disease of the womb may usually be found to account 
for the abnormal loss of blood ; at any rate, till such lesions are carefully ex- 
cluded, the metrorrhagia must not be attributed to the blood condition. 

4. Influence of diabetes on pregnancy and parturition. According to some 
authors, sterility should be the rule in diabetic women ; although this is to a 
certain degree true, yet the rule must be in no wise considered absolute ; in a 
number of cases observed a fair proportion became pregnant, and in one in- 
stance the existence of diabetes in both husband and wife was no bar to con- 
ception. Of course, in estimating the influence of glycosuria on conception 
one ought to take into account the uterine morbid conditions which may 
accompany diabetes. There is little doubt that diabetes does not materially 
affect the course of pregnancy and parturition, but the same cannot be said of 
its influence on the products of conception ; the existence of diabetes in the 
mother seems to exert a serious influence on the child, to alter its nutrition, 
to shorten its life, or to develop vices of development which are scarcely com- 
patible with life; in two out of four observations hydrocephalus was noted. 
The observations of Matthews Duncan confirm the above statements; no 
record is given of diabetes being recognized in the foetus ; according to the 
last named author, childbirth has a baneful effect on women suffering from 
glycosuria; in about seventy per cent, death ensued within a short period 
after delivery. 

5. Effect of pregnancy on diabetes. According to the conclusions ob- 
tained by Dr. Matthews Duncan, pregnancy aggravates almost unfailingly 
the prognosis of diabetes, and the observations on which the paper is founded, 
show, without doubt, that glycosuria increases in intensity after delivery ; an 
attempt has been made to discover whether any relation exists between the 



GYNECOLOGY. 297 

appearance of sugar in the urine of suckling women (as occurs at times nor- 
mally after delivery) and the exacerbation of glycosuria observed in diabetic 
women after parturition, but at present without success. In some cases it has 
been noted that the sugar has disappeared entirely from the urine of diabetic 
patients several days after labor, only, however, to reappear in greater amount 
in the course of a few weeks; in a similar manner, after the menstrual epochs, 
the sugar is materially lessened, but returns to its previous proportions or 
even to greater in a few days. Whatever the temporary effect of either 
menstruation or delivery may be in lessening glycosuria, the final effect in 
causing rapid augmentation of the disease must never be lost sight of. 

The Significance and Diagnosis of Gonorrhoea in Women. 

The Deutsche med. Woch., Oct. 22, 1885, contains a paper by Lomer on this 
subject. Gonorrhoea plays a much more important part in gynecology than 
is generally admitted. As a cause of disease, it ranks next to the puerperium, 
and is at the bottom of a large proportion of the numerous cases of patho- 
logical exudations, perimetritis, fixed displacements of the uterus, cervical 
catarrh, erosions, and sterility which the gynecologist meets with. 

The usually accepted view is due to the fact that gonorrhoea in women is 
often not diagnosed. Not only may the patient be unaware that she is dis- 
eased, but there may be no obvious physical changes to enable even the 
physician to arrive at a diagnosis. The disease may exist without any dis- 
charge or any scalding during micturition, or even any evidence of vaginitis, 
for in many cases the morbid condition is localized in the cervix. 

Lomer has seen many cases in which gonorrhoea, proved to be such by its 
contagiousness, gave rise to none of the ordinary symptoms, but was confined 
to the cervical canal. Examination of the cervical secretion, however, 
showed the characteristic gonococci of Neisser enclosed in the pus cells. 

He quotes some interesting researches by Bumm, in which the latter asserts 
that gonorrhoea in women most frequently affects the cervix, owing to the 
cylindrical epithelium of that region offering the best pabulum to the gono- 
cocci ; while the latter find it difficult to penetrate the squamous epithelium 
(wrongly called mucous membrane) lining the vagina. Bumm, moreover, 
holds that gonorrhceal vaginitis is generally due to the cervical secretions 
causing irritation and inflammation of the vagina much in the same way as 
in gonorrhoea in the male the glans and foreskin may become inflamed 
through want of cleanliness. 

If it is true that cervical gonorrhoea may exist without the vagina being 
necessarily involved, it is easy to explain why so many cases of gonorrhoea in 
women are not diagnosed ; why so many apparently latent cases prove to be 
contagious ; how Ricord came to the conclusion that any vaginal secretion 
might attain the virulence of true gonorrhoeal discharges. Lastly, it would 
show that Noeggerath was to some extent right in his theory of latent 
gonorrhoea. 

Lomer examined the discharges in numerous cases of purulent gonorrhoea, 
with a view to discover Neisser's diplococci. In men their detection proved 
easy. In women, however, he found it quite otherwise, for so many other 
microorganisms were present that the true cocci of Neisser could only be 
made out with great difficulty. Some observers have stated that true gono- 



298 PROGRESS OF MEDICAL SCIENCE. 

cocci can be recognized by their shape and by the colonies they form ; but 
this is questionable. Moreover, Bumm met with several kinds of diplococci 
so much like the true gonococci as to induce him to call them pseudogono- 
cocci. They differ from the true, first, by not occurring within pus corpuscles; 
secondly, by forming irregular groups, and not rounded colonies like true 
gonococci. Lomer, however, was not able to satisy himself as to these differ- 
ences. 

He next attempted to find some characteristic color reaction, which might 
serve for the diagnosis of gonococci; but this, also, he failed tc^do. 

He examined the vaginal secretions of eighty-two hospital out-patients suffer- 
ing from acute and granular vaginitis, urethritis, cervical catarrhs, perimetritis, 
etc., in whom there was ground for suspecting previous gonorrheal contagion, 
with a view of rinding gonococci ; but they could only be made out in seven 
and a half per cent, of all the cases. He concludes, therefore, that vaginal 
secretions are of very little value for the detection of gonococci. When, 
however, he examined cases of suspicious cervical mucus in the same way, he 
found gonococci in all of them (five cases). 

Gonococci are generally considered to be pus corpuscles enclosing diplo- 
cocci. But Lomer considers that even this fact is open to doubt, for exactly 
similar cocci occur in the lochia between the second and sixth days. 

Lomer arrives at the following conclusions : 

1. Vaginal secretions are unsuited for the detection of gonococci. 

2. The latter should be sought for in the cervical secretions. 

3. Only such cases should be looked upon as gonorrhceal in which diplo- 
cocci are found enclosed in pus cells. 

4. It is not as yet justifiable to regard such diplococci as proving the exist- 
ence of gonorrhoea with absolute certainty, since they occur in the mild 
vaginitis of children, and colonies of them are often found in lying-in 
women. 

In the diagnosis of gonorrhoea, clinical symptoms are also of value. The 
virulent affections of the vulva, urethra, and vagina are of diagnostic impor- 
tance, whether they be due directly to contagion, or caused by the irritating 
cervical secretions. Till lately, pointed condylomata and inflammation of 
Cowper's glands were looked upon as pathognomonic, but this is no longer 
quite so certain. 

Purulent cervical catarrhs and erosions are also very suspicious, though 
gonococci have also been found in the transparent cervical discharge. 

Gonorrhoea is a frequent cause of sterility, probably on account of the 
associated endometritis and tubal catarrh. 

Again, scanty menstruation is often secondary to gonorrhoea, and may 
amount almost to amenorrhcea. 

As a last help in diagnosing gonorrhoea in a woman, the history of the hus- 
band should be inquired into. 

Lomer considers that, apart from microscopical characters, there is abun- 
dance of evidence for establishing a diagnosis of gonorrhoea. 

On the Palpation of Pelvic Organs. 

Schultze, in the Centralbl. f. Gyn. for Oct. 24, 1885, records some further 
investigations on the palpation of intrapelvic muscles. He thinks it im- 



GYNECOLOGY. 299 

portant for several reasons, that the gynecologist be able to recognize the 
sometimes contracted, sometimes relaxed, body of the psoas muscle. For 
instance, it affords a good means of finding the ovary in bimanual examina- 
tions. Again, sensitiveness to pressure along the inner edge of the psoas 
where the spermatic vessels cross the posterior pelvic wall, not unfreqnently 
accompanies ovaritis, and long after the termination of parametric affections. 
Schultze has, moreover, known cases in which the persistently contracted 
body of the psoas was mistaken for a morbid growth. 

When this muscle is relaxed, it is so soft that the exploring hand feels the 
pelvic wall while scarcely conscious of the muscle offering any resistance ; 
but if the thigh is forcibly flexed, the pelvic wall can no longer be felt; in- 
stead of it, the finger comes upon the somewhat sensitive body of the muscle, 
forming a hard mass lying in front of the posterior pelvic wall. 

There are two other small muscles which may be of help in explorations of 
the pelvis per vaginam, but which may mislead the inexperienced — the obtu- 
rator internus and the pyriformis. The obturator internus is usually a well- 
developed muscle lying against the antero-lateral wall of the pelvis, and pre- 
senting a broad, firm swelling to the exploring finger, as soon as the thigh is 
forcibly rotated outward ; extension and adduction of the thigh also cause it 
to contract. The portion arising close to the foramen ovale can be distinctly 
felt per vaginam, and also that stretching up along the anterior wall of the 
great ischiatic notch. The body of the muscle, when contracted, is rarely 
sensitive to pressure ; but if the obturator nerve is pressed as it runs in the 
sulcus obturatorius between the muscular fibres, a cramplike pain may be 
felt in the thighs. 

The pyriformis is most accessible in small women with a low pelvis ; when 
the uterus is high, as in advanced pregnancy, the finger can reach above its 
upper edge. 

So far as the evidence from palpation goes, this muscle seems to be very 
unequally developed in different persons ; nor is it thrown so regularly into 
action (as the above) when the thigh is rotated outward. On the other hand, 
it may remain contracted, though the patient is told to lie quite loose. Pres- 
sure on the contracted body of the muscle may be very painful, possibly owing 
to such pressure being transmitted to the sacral nerves. All these characters 
may be the source of error. Schultze himself has mistaken the pyriformis for 
ovaries adherent to the posterior pelvic wall. 

The obturator is not very likely to be mistaken for a tumor, since its surface 
forms a gentle convexity. But the pyriformis when well developed rises 
steeply from the anterior surface of the sacrum to the height of sometimes two 
centimetres (0.8 inch), while there is a space of about three centimetres (1.2 
inch) between the two muscles. Two fingers, the tips of which are placed on the 
sacrum, can simultaneously feel the two pyriformes contracting or relaxing, 
and this is a great help in the diagnosis. The mere fact of telling a patient 
who is lying loosely to stiffen her thighs, is often enough to throw the pyri- 
formes into action. The recognition of this contraction and relaxation will 
prevent any risk of mistaking this muscle for a tumor. 



300 PKOGRESS OF MEDICAL SCIENCE 



MEDICAL, JURISPRUDENCE AND TOXICOLOGY. 



UNDER THE CHARGE OF 

MATTHEW HAY, M.P., 

PROFESSOR OF MEDICAL JURISPRUDENCE, UNIVERSITY OF ABERDEEN. 

Lung Test in Infanticide. 

Sommer, of Dorpat ( Viertelj.f. gericht. Med., Bd. xliii. S. 253-260), furnishes 
a contribution to the controversy which has been carried on for over three 
years, as to the effect of Schultze's method of artificial respiration on the 
reliability of the hydrostatic lung test in cases of infanticide. It will be re- 
membered that, in 1883, Runge called attention to the fact that Schultze's 
method of swinging the child was not only efficient in causing apparently 
dead newborn children to respire, but was also capable of more or less dis- 
tending the lungs of really stillborn children ; and he therefore urged the 
importance of bearing this in mind in cases of alleged infanticide. The pos- 
sibility of such inflation being produced in the dead child by Schultze's 
method — whereas it is well known that all previous methods of artificial 
respiration have failed to produce such an effect — is, apart from actual direct 
experimentation on the dead, rendered more likely since Torggler has recently 
shown, by a series of careful experiments ( Wien. medic. Bl., 1885, Nos. 8-10), 
that Schultze's method is of all methods of artificial respiration the most cer- 
tain in restoring newborn children. Direct experiment on the dead is attended 
with difficulty, since it is in the great majority of cases difficult to prove that 
the inflation of the lung was not produced by some unobserved inspiration 
during or after the birth of the child. Hence so eminent an authority, as 
Hofmann, of Vienna, maintains that the air found by Runge and others in 
the lungs of stillborn children, after manipulation by Schultze's method, has 
really entered the lungs before, and is the result of aborted natural respira- 
tion. He himself has made the experiment with absolutely stillborn chil- 
dren, but found no air in the lungs. It is alleged, however, by Runge, and 
those who agree with him, that the children with which Hofmann made his 
experiments were not full-grown foetuses, and that immature foetuses (eight 
months and under) are known not to have their lungs affected by Schultze's 
method. This allegation appears to be borne out by a reference to the chil- 
dren operated on by Hofmann. 

Prof. Schauta has written a paper in which he supports Runge; while, in 
a still more recent paper, Dr. Nobiling takes the side of Hofmann. Sommer, 
who is Runge's assistant, now takes up the pen in defence of his chief, and 
produces the protocols of two cases in Runge's clinic which appear to place it 
beyond doubt that Schultze's method is capable of more or less inflating the 
lungs of stillborn children so as to simulate respiration. Both children — one 
of which was a twin — were mature, or nearly mature, and both were ascer- 
tained by auscultation, and otherwise, to have been alive to within a short 
time of the completion of their delivery, previous to which they were with 
great certainty ascertained to have died, and before there was any possibility 



MEDICAL JUKISPKUDENCE AND TOXICOLOGY. 301 

of their having breathed — in one case before the membranes had ruptured. 
In each case the child was swung thirty times, according to Schultze's method. 
On opening the chest, the lungs in both children were found to be distended 
and mottled ; and although they did not swim in water when attached to the 
thymus and the heart, they floated readily by themselves, as did also the 
greater number of small pieces into which the lungs were divided. The only 
uninflated portions were toward the base of the lungs. This confirmation of 
Runge's results is becoming the more important, since nurses are now being 
trained in several parts of the world in the practice of Schultze's method of 
artificial respiration. It adds a new difficulty to the many difficulties attend- 
ing the medico-legal investigation of cases of alleged infanticide. 

State of the Pupil after Death. 

Dr. J. N. Marshall, of Glasgow, has contributed to the Lancet (August 
15, 1885, pp. 286-288) a paper on the changes which take place in the pupil 
after death, and the action of certain poisons on the dead eye. He concludes, 
from a tolerably large number of observations, that the pupils generally dilate 
immediately previous to death, even though they may have been previously 
much contracted, as, e. g., in cases of opium-poisoning. Further, that in the 
majority of cases the pupil within an hour after death begins again to con- 
tract gradually, and goes on contracting for about forty-eight hours. This 
contraction, which is considerable (e. g., 7.2 mm. to 4.6 or 3.8 mm.), is inde- 
dendent of the action of light, or of rigor mortis. Atropine, when dropped on 
the eye, after death, causes slight dilatation. The eye retains its susceptibility 
to the action of atropine for about four hours after death. [The conclusion 
for medico-legal purposes evidently remains as it was, viz., that no value can 
be attached to the state of the pupil at or after death as an indication of the 
mode of death. — Rep.] 

Different Putrefactive Appearances in the Corpses of Two 
Individuals who Died under exactly similar Circumstances. 

Meyer, of Heilsberg ( Viertelj.f. gerichtl. Med., N. F., Bd. xliv. S. 101-103, 
1886), describes the case of a man and his wife, aged seventy-two and sixty- 
five, respectively, who were found dead in bed, apparently having died from 
carbonic oxide poisoning. The stove in the small room had its damper 
closed. The man had been a drunkard, and the woman had suffered for many 
years from bronchitis. The bodies of both were seen by Meyer about thirty- 
six hours after the supposed period of death, and they were found to present 
the appearances characteristic of death by carbonic oxide — bright red spots 
on the surface, and a bright red color of the blood, which, when tested, was 
found to contain carbonic oxide. But, although the bodies were dead from 
the same cause, had died probably about the same time, were about equally 
developed and nourished, and had lain in bed under exactly the same condi- 
tions, yet they presented within thirty-six hours a remarkable difference in 
the degree of putrefaction. The corpse of the woman was perfectly fresh, had 
no putrefactive odor, and was not discolored except over the abdomen, where 
there was a slight greenish discoloration. That of the man, on the contrary, 
was considerably putrefied ; the subcutaneous tissue was greatly distended 



302 PROGRESS OF MEDICAL SCIENCE. 

with putrid gases, rendering the individual almost unrecognizable; the face 
was greatly swollen, the penis was of the thickness of a child's arm, and the 
scrotum was as large as a child's head. The skin was much discolored ; on 
the head it was greenish-red ; on the back, upper arms, and thighs, it was 
distinctly green. The veins showed through the skin as dirty brownish-red 
streaks. The epidermis was in many parts blistered, rigor mortis had 
entirely disappeared, and the putrefactive odor was very strong. Eight days 
later, the putrefactive appearances had not much altered in the woman. In 
the man, they had become still more marked. Meyer concludes with the 
remark that, when he first saw the corpses — that is, thirty-six hours after 
death — the putrefactive appearances were such as might have led him to infer 
that the woman had been dead for twenty-four to thirty-six hours, but that 
the man had been dead for fourteen to twenty days. Yet both were seen 
alive by their neighbors on the night previous to the accident. 

Sulphuretted Hydrogen. 
Brouardel and Loye (La France Medicate, Sept. 5, 1885) have made a 
number of experiments on tracheotomized dogs with sulphuretted hydrogen 
the animals being poisoned by the inhalation of a half or a two per cent, mix- 
ture of the gas with air. The stronger mixture killed a dog in two or three 
minutes, the weaker in seventeen to fifty minutes. The observers believe 
that, in the former case, death is due to the direct action of the gas on the 
nervous centres ; whereas, in the latter, this action is aided by asphyxia. In 
both, the pupil dilates, and is insensible to light, and the cornea is insensitive; 
but, after awhile, if the dilute mixture is being inhaled, the sensitiveness of 
the cornea returns. In this case also the respiratory movements at first cease 
and then begin again, and gradually increase in amplitude, although with 
lessening frequency, until death ensues. Under the more concentrated poison, 
respiration quickly ceases, and with it all reflex movements. The blood 
coagulates readily, and has a violet color in thin layers. It contains a fair 
amount of oxygen. 

Ptomaines. 

Among the recent numerous contributions to our knowledge of the poison- 
ous action of diseased or putrid flesh, the following are worthy of notice: 

Lehnert (Ber. ub. d. Veterinarwesen im Kgr. Sachsen., 1883, p. 94) states 
that he has frequently observed that the flesh of cows which have suffered 
from metritis after parturition, and in which at the same time the placenta 
was wholly or partially retained, produces distinct poisonous symptoms when 
eaten — vomiting and purging — even where the metritis has existed for a few 
days only. 

Oeffingfr (Die Ptomaine, Wiesbaden, 1885) has separated several alkaloids 
from the flesk of decaying white fish (Leuciscus alburnus)); one of the alka- 
loids has a curara-like action. 

Salkowski (Zeitschrift f. physiol. Chem., ix. S. 8 u. S. 23, 1885) describes at 
considerable length the mode of preparation, chemical properties, and phys- 
iological action of a new product of the putrefaction of albuminoids, which he 
designates "skatolcarbon-saure." The behavior of this acid with dilute ferric 
chloride is peculiar and characteristic, the mixture assuming a dirty grayish- 



MEDICAL JUKISPKUDENCE AND TOXICOLOGY. 303 

blue color. If the mixture now be acidulated with hydrochloric acid, a gray- 
ish-violet precipitate is formed, which, if separated by filtration, will be found 
to dissolve in alcohol with a cherry-red color. Salkowski has found the acid 
in normal urine, and believes it to be a normal constituent ; its quantity is 
increased in ileus, peritonitis, etc. 

Lepine and Gtjerin (Journ. d. pharm. et d. chim., xi. p. 162, 1885) have 
found that healthy human urine causes myosis, abolition of the reflexes, slow- 
ing of the respiration, and death when injected into the circulation of rabbits; 
60 c.c. (2 ounces) suffice to cause death. They have succeeded in separating 
poisonous alkaloids from the urine of patients suffering from typhus, pneumo- 
nia, diabetes, and jaundice. 

Hager (Pharm. CentralbL, No. 18, p. 213) reports the poisoning of five cows 
from drinking water in which guano sacks had been washed, and attributes 
the poisonous effects to the presence of ptomaines in guano. 

Bocklisch (Ber. d. deutsch. chem. Ges., xviii. S. 86 u. 1922) communicates 
an interesting article on the ptomaines obtained from putrid fish, and points 
out that different kinds of fish produce different alkaloids. He carefully 
analyzed the products of putrefaction of herrings, and found that besides 
cadaverine, putrescine, and gadinine, there was present a large quantity of 
trimethylamine, and methylamine. These latter alkaloids have not yet been 
obtained from any other variety of putrid fish. 

Poisoning by Cheese. 

Vaughan (Board of Health Report, State of Michigan, U. S., 14th July, 
1885) divides poisonous cheeses into two classes : first, those which are poison- 
ous on account of their accidentally containing poisonous metallic salts, or 
because they are prepared from the milk of animals which have fed upon 
poisonous plants, as veratrum, euphorbium, etc. ; and, secondly, those which, 
innocuous at first, become poisonous after being kept for some time, owing to 
the development of poisonous products. It is those products which Vaughan 
has particularly investigated, and he has been able to separate a crystalline 
body, which he names tyrotoxicon (from rvpog, cheese), and which appears to 
produce poisonous effects similar to those caused by cheese. 

Alleged Homicide by Chloboform-poisoning. 

A case of this nature, known as the Bartlett case, and which has recently 
excited much attention in England, has been brought to a conclusion by the 
acquittal of the prisoner, who was the wife of the man supposed to be 
poisoned by chloroform. The peculiarity of the case was that the chloroform 
had been swallowed — not inhaled — and that it was alleged by the prosecuting 
counsel that, in order to prevent her husband, who was sick in bed, resisting 
the drinking or swallowing of the chloroform, the accused had first of all ren- 
dered him partly insensible by the inhalation of chloroform vapor, and then 
poured chloroform into his mouth. Chloroform was found in the stomach. 
Although the accused was acquitted, there were several circumstances which 
raised a strong suspicion of homicide. This is the first case of alleged poison- 
ing by the swallowing of chloroform which has come into court. 



304 PKOGRESS OF MEDICAL SCIENCE. 

Alleged Poisoning by Colchicine. 
Brouardel (Anna!, d'hyg.publ., Ser. 3, t. xv. pp. 230-283) communicated 
to the Soc. de Medecine Legale de France, on January 11, 1886, the result of 
a lengthened investigation of a case of supposed homicide by colchicine. 
The body of the deceased was examined eight months after death. The 
symptoms immediately preceding death indicated gastric irritation — vomit- 
ing, diarrhoea, etc. — and were such as not to exclude the hypothesis that 
death had been caused by colchicine. At the autopsy no natural cause of 
death was discoverable. The body was in an excellent state of preservation, 
and might have been dead for only a few days instead of eight months. The 
chemical analysis of the organs revealed the presence of an alkaloid which 
gave the reactions of colchicine. The organs examined were the stomach, 
intestines, liver, kidneys, heart, brain, and lungs. They were extracted by 
means of alcohol containing tartaric acid. The evaporated extract was dis- 
solved in dilute alcohol, and was shaken with petroleum ether in order to 
remove fatty matters. The ethereal fluid was poured off, and chloroform 
was then added to the purified alcoholic fluid and shaken with it, in order to 
dissolve out the colchicine. In this manner a yellowish resin-like semi- 
solid residue was obtained, possessing the odor of skatol. On adding a 
drop of nitric acid (specific gravity 1.4), a feeble violet coloration was 
obtained which speedily disappeared ; a small quantity of potash was now 
added and produced an orange-red coloration. These reactions are generally 
regarded as characteristic of colchicine. Another portion of the extract was 
further purified and tested by means of potassium teriodide, and other 
alkaloidal precipitants, and was found to be precipitated by each. The 
physiological action of the extract was tried on a dog, but without any 
decided effect. Brouardel and the experts associated with him, therefore, 
concluded that the results of their examination were consistent with the 
hypothesis that the deceased died by colchicine. The juge d 'instruction, 
after receiving this report, committed the ca<t to Vulpian and Schutzen- 
berger, in order that a fresh investigation might be made of it. These 
experts came to the same conclusion as Brouardel. In addition to the nitric 
acid and potash test, they employed the reaction with sulphovanadate of 
ammonia, lately suggested by Mandelin, a pupil of Dragendorff, as a test for 
colchicine. This reagent, dissolved in sulphuric acid (1 in 200), gives an 
intense green coloration with colchicine which rapidly passes into a brownish- 
violet. The accused was acquitted. 

The Results of Recent Investigations of Pork. 

Dr. Herrmann Eulenberg, in the Viertelj.f. gerichtl. Med., 1886, N. F. 
Bd. xliv. S. 150-161, summarizes the results of the various recent investiga- 
tions of the flesh of swine, and ^ates the following conclusions : (1) Pork 
which contains single concretions of an unknown character, or concretions 
composed of distomae or haplococci in small quantity, is fit for consumption. 
(2) Pork which contains trichinae or which is measly, may be used under 
proper restrictions. (3) Pork which contains numerous concretions, whatever 
be their cause, or actinomycetes, should only be employed for the prepara- 
tion of lard. 



THE 



AMERICAN JOURNAL 

OF THE MEDICAL SCIENCES 



OCTOBER, 1886. 



CONTRIBUTORS TO THIS VOLUME. 

SAMUEL ASHHURST, M.D., Surgeon to the Children's Hospital, Philadelphia. 

I. E. ATKINSON, M.D., Professor of Therapeutics, Materia Medica, and Clinical Medicine in the University 

of Maryland. 
ROBERTS BARTHOLOW, M.D., Professor of Therapeutics in Jefferson Medical College, Philadelphia. 
ROBERT BATTEY, M.D., of Rome. Ga., formerly Professor of Obstetrics in the Atlanta Medical College. 
JOHN VAN BIBBER, M.D., of Baltimore. 

CLARENCE J. BLAKE, M.D., Instructor in Diseases of the Ear, Harvard University. 
BYROM BRAMWELL, M.D., F.R.C.P. Epin , Assistant Physician to the Edinburgh Royal Infirmary. 
CHARLES STEADMAN BULL, M.D., Lecturer on Ophthalmology in the Bellevue Hospital Medical College 
CHARLES H. BURNETT, M.D., Professor of Otology in the Philadelphia Polyclinic. 
FRANCIS H. CHAMPNEYS, M.D., Obstetric Physician to St. George's Hospital, London. 
JOHN B. CHAPIN, M.D., Physician-in- Chief of the Pennsylvania Hospital for the Insane, Philadelphia. 
W. WATSON CHEYNE, M.D., F.R.C.S., Assistant Surgeon to King's College Hospital, London. 
J. SOLIS COHEN, M.D., Professor of Diseases of the Throat and Chest, Philadelphia Polyclinic. 
W. J. CONKLIN, M.D., of Dayton, Ohio. 

F. R. CROSS, M.B. Lond., F.R.C.S., Ophthalmic Surgeon to the Bristol Royal Infirmary. 
Sir WILLIAM A. DALBY r , F.R.C.S.. Aural Surgeon to St. George's Hospital, London. 
JOHN C. DALTON, M.D., late Professor of Physiology in the College of Physicians and Surgeons, N. Y. 
D. BRY'SON DELAVAN, M.D., Professor of Laryngology and Rhinology in the New York Polyclinic. 
F. DONALDSON, Jr., M.D., Chief of Clinic for the Throat and Chest, University of Maryland. 
LOUIS A. DUHRING, M.D., Professor of Dermatology in the University of Pennsylvania. 
CHARLES W. DULLES, M.D., Surgeon to Outpatient Department, Hospital of University of Pennsylvania. 
CHARLES FINLAY, M.D., of Havana, Cuba. 

REGINALD H. FITZ, M.D., Shattuck Professor of Pathological Anatomy in Harvard University. 
WILLIAM H. FORD, M.D., of Philadelphia. 

J. P. CROZER GRIFFITH, M.D., Assistant Demonstrator of Normal Histology in University of Penna. 
R. J. HALL, M.D., of New York. 

A. W. HARE, M.D., Assistant to the Professorof Surgery in the University of Edinburgh. 
ROBERT P. HARRIS, M.D., of Philadelphia. 
D. BERRY HART, M.D., of Edinburgh. 

P. F. HARVEY', M.D., Captain and Assistant Surgeon U. S. A. 

MATTHEW HAY, M.D., Professor of Medical Jurisprudence, University of Aberdeen. 
ALFRED HEGAR, Professor of Obstetrics and Gynecology in the University of Freiburg. 
GUY HINSDALE, M.D., of Philadelphia. 

JONATHAN HUTCHINSON, F.R.S., LL.D., Emeritus Professor of Surgery to the London Hospital. 
EDWARD JACKSON, M.D., of Philadelphia. 
RICHARD J. KINKEAD, M.D., Professor of Obstetric Medicine, and Lecturer on Medical Jurisprudence 

in Queen's College, Gahvay. 
MORRIS J. LEWIS, M.D., Physician to the Episcopal Hospital, Philadelphia. 
JOHN N. MACKENZIE, M.D., Surgeon to the Baltimore Eye, Ear, and Throat Charity Hospital. 
R. OSGOOD MASON, M.D., of New York. 
WALTER MENDELSON, M.D., Instructor in the Physiological and Pathological Laboratory of the College 

of Physicians and Surgeons, New York. 
S. WEIR MITCHELL, M.D., I hysician to the Infirmary for Nervous Diseases, Philadelphia. 
SHIRLEY F. MURPHY', M.R.C.S., of London. 

CHARLES B. NANCREDE, M.D., Surgeon to the Episcopal Hospital, Philadelphia. 
WILLIAM OSLER, M.D., Professor of Clinical Medicine in the University of Pennsylvania. 
CHARLES B. PENROSE, M.D., Resident Physician at the Pennsylvania Hospital. 
HENRY G. RAYMOND, M.D., Assistant Surgeon U. S. A. 

JOSEPH G. RICHARDSON, M.D., Prof essor of Hygiene i n the University of Pennstjlvauia. 
A. SYDNEY ROBERTS, M.D., Instructor in Orthopaedic Surgery, University of Pennsylvania. 
T. M. ROTCH, M.D., Instructor of Diseases in Children in Harvard University. 
NICHOLAS SENN, M.D., Attending Surgeon to the Milwaukee Hospital. 
WILLIAM H. SHERMAN, M.D., Assistant Surgeon to the Presbyterian Hospital, New York. 
J. LEWIS SMITH, M.D.. Clinical Professor of the Diseases of Children in Bellevue Hospital Medical 

College, N. Y. 
HENRY W. STELWAGON, M.D., Physician to the Philadelphia Dispensary for Skin Diseases. 
GEORGE M. STERNBERG, M.D., Major and Surgeon U. S. A. 

GEORGE D. THANE, M.R.C.S. Eng., Professor of Anatomy at University College, London. 
FREDERICK TREVES, F.R.C.S., Surgeon to, and Lecturer on Anatomy at, the London Hospital. 
JAMES TYSON, M.D., Professor of General Pathology in the University of Pennsylvania. 
J. COLLINS WARREN, M.D., Assistant Professor of Surgery at Harvard University. 
Sir T. SPENCER WELLS, Bart., late President of the Royal College of Surgeons of England. 
RANDOLPH WIN SLOW, M.D., Lecturer on Clinical Surgery in the University of Maryland. 
GERALD F. YEO, M.D., Professor of Physiology at King's College, London. 



TO HEADERS AND CORRESPONDENTS. 



All communications intended for insertion in the Original Department of this Journal are only 
received for consideration with the distinct understanding that they are sent for publication to this 
Journal alone, and that abstracts of them shall only appear elsewhere subsequently, and with due 
credit. Gentlemen favoring us with their communications are considered to be bound in honor to a 
strict observance of this understanding. 

Contributors who wish their articles to appear in the next number are requested to forward them 
before the 10th of October to the Editor, 

No. 1004 Walnut Street, Philadelphia, U. S. A. ; or 

No. 63 Montagu Square, Hyde Park, W. London, England. 

Liberal compensation is made for articles used. Extra copies, in pamphlet form with cover, will 
be furnished to authors in lieu of compensation, provided the request for them be written on the manuscript. 

The following works have been received for review : 

A System of Practical Medicine. By American Authors. Edited by William Pepper, M.D., LL.D., 
Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the Univer- 
sity of Pennsylvania. Assisted by Louis Starr, M.D., Clinical Professor of Diseases of Children in the 
Hospital of the University of Pennsylvania. Vol. V. Diseases of the Nervous System. Philadelphia : 
Lea Brothers & Co., 1886. 

Bright's Disease, and Allied Affections of the Kidneys. By Charles W. Purdy, M.D. (Queen's 
Univ.), Professor of Genito-Urinary and Renal Diseases in the Chicago Polyclinic, etc. With new and 
original illustrations. Philadelphia : Lea Brothers & Co., 1886. 

A Manual of Practical Therapeutics, considered with reference to Articles of the Materia Medica. 
By Edward John Waring, C.I.J., M.D. London. Edited by Dudley W. Buxton, M.D., B.S. Lond. 
Fourth edition. Philadelphia : P. Blakiston, Son & Co., 1886. 

A Treatise on the Diseases of the Nervous System. By William A. Hammond, M.D., Surgeon- 
General U. S. Army (retired list), Professor of Diseases of the Mind and Nervous System in the New 
York Post-Graduate Medical School. New York : D. Appleton & Co., 1886. 

Medicine of the Future. An Address prepared for the Annual Meeting of the British Medical Asso- 
ciation in 1886. By Austin Flint (Senior), M.D., LL.D. New York : D. Appleton & Co., 1886. 

Analysis of the Urine. With Special Reference to the Diseases of the Genito-Urinary Organs. By 
H. B. Hofmann, Professor in the University of Gratz, and R. Ultzmann, Docent in the University 
of Vienna. Translated by T. Barton Brune, A.M., M.D., late Professor of the Practice of Medicine 
in the Baltimore Polyclinic and Post-Graduate Medical School, and H. Holbrook, Curtis, Ph.B., M.D., 
Fellow of the New York Academy of Medicine. Second edition, revised and enlarged. New York : 
D. Appleton & Co., 1886. 

Studies in Pathological Anatomy. By Francis Delafield, M.D., Professor of Pathology and Practi- 
cal Medicine, College of Physicians and Surgeons, New York. Vol. II. Part 2. Chronic Phthisis ; 
Lobar Pneumonia. Plates XIII-XXXIX. New York : William Wood & Co., 1886. 

Diseases of the Stomach and Intestines. A Manual of Clinical Therapeutics for the Student and 
Practitioner. By Professor Dujardin-Beaumetz, Physician to the Cochin Hospital. Translated from 
the fourth French edition. By E. P. Hurd, M.D., President of the Essex North District Medical 
Society. New York : William Wood & Co., 1886. 

Manual of Differential Medical Diagnosis. By Condict W. Cutler, M.S., M.D., Physician to the 
New York Dispensary. New York : G. P. Putnam's Sons, 1886. 

On Disorders of Digestion. Their Consequences and Treatment. By T. Lauder Brunton, M.D., 
F.R.S., Assistant Physician and Lecturer on Materia Medica at St. Bartholomew's Hospital, London. 
London : Macmillan & Co., 1886. 

The Private Treatment of the Insane as Single Patients. By Edward East, M.R.C.S., L.S.A., 
Member of the Medico-Psychological Association, London. London : J. & A. Churchill, 1886. 

The Modern Treatment of Stone in the Bladder by Litholapaxy. A Description of the Operation and 
Instruments, with Cases Illustrative of the Difficulties and Complications met with. By P. J. Freyer, 
M.A., M.D., M.Ch., Bengal Medical Service, Civil Surgeon, Mussoorie. London : J. & A. Churchill, 
1886. 

A Code of Rules for the Prevention of Infectious and Contagious Diseases in Schools. Being a Series 
of Resolutions passed by the Medical Officers of Schools Association, January 7, 1885. Second edition. 
London : J. & A. Churchill, 1886. 



308 TO READERS AND CORRESPONDENTS. 

The Middlesex Hospital. Reports of the Medical, Surgical, and Pathological Registrars for the year 
1884. London : H. K. Lewis, 1886. 

Guy's Hospital Reports. Edited by Frederick Taylor, M.D., and N. Davies-Colley, M.A., M.C. 
Vol. XLIII. London : J. & A. Churchill, 1886. 

Transactions of the Obstetrical Society of London. Vol. XXVIII. For the year 1886. Part 2, for 
March and April. London, 1S86. 

Manual of Operative Surgery. By W. Arbuthnot Lane, M.B., M.S., F.R.C.S., Senior Demonstrator 
of Anatomy, Guy's Hospital. London : George Bell & Sons, 1886. 

Spasm in Chronic Nerve Disease. Being the Gulstonian Lectures delivered at the Royal College of 
Physicians of London, March, 1886. By Seymour J. Sharkey, M.A , MB. Oxon , Assistant Physician 
and Joint Lecturer on Pathology at St. Thomas's Hospital. London, 1886. 

The Unity or Duality of Syphilis Historically Considered. By J. L. Milton, Senior Surgeon to St. 
John's Hospital for Diseases of the Skin. (From a paper read before the Wellan Society.) 

The Pathology and Treatment of Dropsy. By James Barr, M.D., F.R.C.S. Edinb., Physician to the 
Stanley Hospital, Liverpool. 

The Retrospect of Medicine. Vol. XCIII. January-June, 1883. London : Simpkin, Marshall & 
Co., 1886. 

Lehrbuch der Physiologie fiir akademische Vorlesungen und zum Selbstudium. Part 10. By Dr. 
A. Gruenhagen. 

Ueber das Verhalten verschiedener Bacterienarten in Trinkwasser. Von Meade Bolton, M.D. 
(Univers. Va.), aus Richmond, Virginia, U. S., 1886. 

Papillom am 5 Luftrokrenknorpel auf laryngoscopischem Wege entfernt. Yon Dr. C. Labus, aus 
Mailand, 1886. 

Ichthyol und Resorcin als Representanten der Gruppe reduzierender Heilmittel. Yon Dr. P. T. 
Unna, 18S6. 

Traite Pratique et Descriptif des Maladies de la Peau. Par Alfred Hardy, Professeur de Clinique 
Medicale a la Faculte de Medecine de Paris, Medecin de l'HSpital de la Charite. Paris : J. B. Bailliere 
et Fils, 1886. 

Traite Elementaire d'Anatomie Medicale du Systeme Nerveux. Par Cii. Fere, Medecin adjoint de 
la Salpetriere. Paris, 1886. 

Monomanie Sans Delire. An Examination of the "Irresistible Criminal Impulse Theory." By A 
Wood Benton, M.A., LL.B., of Gray's Inn, and of the Oxford Circuit, Barrister-at-Law. Edinburgh : 
T. & T. Clark, 1886. 

Nuovo Metodo di Cura Chirugico delle Granulazioni Congiuntivale, proporto. Dal Dr. Cecchini 
Settimo, Assistente d'Anatomia Patologica nella R. Universita di Modena. 

Istituto Anatomo-Patologico della R. Universita di Modena. Sulla Riproduzione Sperimentale della 
Milza nei Polli, Cani, Conigli e Rane, Comunicazione Preventiva Faita alia Societa Medico Chir. di 
Modena. Dal Dott Cecchini Settimo, Assistente nell' Istituto Anatomo-Patoligico della R. Univ. di 
Modena. Modena, 1886. 

Sulla Presunta Riproduzione Totale della Milza Seconda Comunicazione Preventiva. Pel Dott Cec- 
chini Settimo, Assistente nell' Istituto Anatomo-Patoligico de la R. Univ. di Modena. Modena, 1886. 

Delle Injezioni di Olio Essenziale di Frementina per la Cura Radicale delle Fistole Anali della Carie 
dell' Asso Petroso delle Fistole Dentarie del Condotto Stenoniano e delle Fistole Atoniche. Del Dott 
Cecchini Settimo, Gia Assistente di Anatoinia Patoligica nelle R. Univ. di Messini. Milano, 1885. 

Istituto Anatoma Patologico della R Univ. di Modena. Ectopia Congenita della Testa del Pancreas 
e Consecutiva Gastrectasia. Pel Dott Cecchini Settimo, Assistente nell' Istituto Anatomo Patologico 
della R. Univ. di Modena. Modena, 1886. 

Afasia e Sue Forme. Del Dott Guido Banti. Firenze, 1886. 

Banti Dott Guido. Studio Sulla Pergussione del Guore. Firenze, 1886. 

Banti Dott Guido. Meningite Cerebrale e same Batteriosgopigo. Firenze, 1886. 

Enucleation with Transplantation and Reimplantation of Eyes. By Charles A. May, M.D., Instruc- 
tor in Ophthalmology, New York Polyclinic. New York, 1886. 

Yucca Angustifolia : A Chemical Study. By Helen C. De S. Abbott, Fellow of the American Asso- 
ciation for the Advancement of Science. Philadelphia, 1886. 

Papers upon Genito-Urinary Surgery. By A. T. Cabot, M.D., Surgeon at the Massachusetts General 
Hosptal. I. Nephrotomy for Hydronephrosis; Recovery. II. The Constrictor Urethras Muscle; its 
Relations to Urethral Pathology, and Treatment. III. Case of Multiple Calculi in the Bladder. IV. 
The Application of Antiseptic Principles to Genito-Urinary Surgery. Boston, 1886. 

Circulars of Information of the Bureau of Education. No. 5, 1885. Physical Training in American 
Colleges and Universities. By Edward Mussey Hartwell. Ph.D., M.D., of Johns Hopkins University. 
Washington, 1886. 

Malarial Manifestations due to Traumatism. By Henry C. Coe, M.D., M.R.C.S. 1886. 

Sketch of the Early History of Anatomy. By Francis J. Shepherd, M.D., Professor of Anatomy, 
McGill University. 



TO READERS AND CORRESPONDENTS. 309 

On the Affections of the Skin induced by Temperature Variations in Cold Weather ; with Incidental 
Reference to the so-called "Prairie Itch," "Ohio Scratches," "Michigan Itch," "Texas Mange," 
" Camp Itch," "Prairie Digs," "Lumbermen's Itch," "Swamp Itch," etc., and some Consideration of 
their Relation to Cutaneous Pruritus, Winter Prurigo, Winter Eczema, Scabies, etc. By James Nevins 
Hyde, M.D., Professor of Skin and Venereal Diseases, Kush Medical College, Chicago. Chicago, 1886. 

Twenty-fifth Annual Report of the Professor of Physical Education and Hygiene to the Board of 
Trustees of Amherst College, June 20, 1886. 

Report of a Successful Transfusion in Typhoid Fever. By Wii. S. Whitwell, A.M., M.D. 1886. 

The Negro Problem from a Medical Standpoint. By F. Tipton, M.D. Selma, Ala., 1886. 

A Contribution to the Pathology of Hemianopsia of Central Origin (Cortex Hemianopsia). By E. C. 
Seguin, M.D., Clinical Professor of Diseases of the Mind and Nervous System in the College of Physi- 
cians and Surgeons, New York. 

On the Limitation of the Contagious Stage of Syphilis ; especially in its Relations to Marriage. By 
F. N. Otis, M.D., Clinical Professor of Genito-Urinary Diseases in the College of Physicians and Sur- 
geons, etc., New York. New York, 1886. 

Memoir of Austin Flint, M.D., LL.D. By A. Jacobi, M.D., President of the New York Academy of 
Medicine. New York, 1886. 

Nitro-Glycerine in the Treatment of Chronic Nephritis. By Francis Kinnicutt, M.D., Physician to 
the St. Luke's Hospital and the New York Cancer Hospital. New York, 1886. 

Permanent Drainage for Ascites. By Llewellyn Eliot, M.D., Washington, D.C. 

Osteo-Sarcoma of the Orbit. By Charles W. Kollock, M.D. Charleston, S. C. 

Intubation of the Larynx for Diphtheritic Croup. By E. Fletcher Ingals, A.M., M.D., Professor 
of Laryngology, Rush Medical College. Chicago, 1886. 

Electrolysis in Gynecology. With a Report of Three Cases of Fibroid Tumor Successfully Treated 
by this Method. By Franklin H. Martin, M.D., Professor of Gynecology in Chicago Polyclinic. 
Chicago, 1886. 

Classification of Mental Diseases as a Basis for International Statistics regarding the Insane. By 
Clark Bell, Esq. 

Internatio nal Electrical Exhibition, 1884. Report of Examiners of Section XXIII. Electro-Medical 
Apparatus. Philadelphia, 1886. 

Progressive Muscular Atrophy, beginning in the Legs. By J. B. Marvin, M.D., Professor of Prin- 
ciples and Practice of Medicine and Clinical Medicine in the Kentucky School of Medicine. 

The Aim and Purpose of the Medical Man. By J. B. Marvin, M.D., Professor of Principles and 
Practice of Medicine and Clinical Medicine in the Kentucky School of Medicine, Louisville, Ky. 

Meconeuropathia. By C. H. Hughes, M.D., St. Louis, Mo. 

A Visit to Gheel. By Charles W. Pilgrim, M.D., Assistant Physician to the New York State 
Lunatic Asylum, Utica, N. Y. 

The Value of the Knee Phenomenon in the Diagnosis of Disease of the Nervous System. By Philip 
Zenner, A.M., M.D., Lecturer on Diseases of the Nervous System in the Medical College of Ohio, 
Cincinnati. Chicago, 1886. 

Typhoid Fever; its Cause and Prevention. By J. F. Kennedy, M.D., Secretary of Iowa State Board 
of Health. 

Health Laws of the State of Iowa, compiled by the State Board of Health, 1886. 

On some Points of Interest Connected with the Wanklyn Method of Sanitary Water Analysis, par- 
ticularly on the Detection of Recent Sewage, and the Determination of the Nature of the Organic Matter. 
By Charles Smart, Major and Surgeon U. S. Army. 

Malarial Hematuria. By R. H. Day, M.D., Baton Rouge, La. 

Medical Expert Testimony and the Hypothetical Question. By William C. Wey, M.D., Elmira, N. Y. 

The Treatment of White Swelling of the Knee. By A. B. Judson, M.D., Orthopaedic Surgeon to the 
Outpatient Department of the New York Hospital. 

Hard Chancre of the Eyelids and Conjunctiva. By David De Beck, M.D. Cincinnati, 1886. 

Medical Education and Medical Licensure. An Address'delivered before the Twenty-third University 
Convocation, at Albany, July 9, 1886. By Wm. H. Watson, A.M., M.D., Regent of the University of 
the State of New York. Albany, 1886. 

Transactions of the South Carolina Medical Association. Thirty-sixth Annual Session, held in Camden, 
S. C, April, 1886. Charleston, S. C, 1886. 

Transactions of the Medical Society of the State of West Virginia. Nineteenth Annual Session, 
held at Charleston, May, 1886. Wheeling, 1886. 

Proceedings of the Academy of Natural Sciences of Philadelphia. Part I. January to March, 1886. 

Report of the Board of Health of Paterson, New Jersey. 1885-1886. With Appendix. 

Annual Report of the State Board of Health of New York. April 9, 1885. 

Annual Report of the Provincial Board of Health of Ontario, for the year 1885. Toronto, 1886. 

Reports of Proceedings of the Michigan State Board of Health. July 13, 1886. 



310 



TO READERS AND CORRESPONDENTS, 



Excerpta from the Biennial Report of the Board of Health of the State of Louisiana, 1884-1885. 
James Holt, M.D., President. New Orleans, 1886. 

Annual Report of the Officers of the Retreat for the Insane, at Hartford, Conn., April, 1886. Hart- 
ford, Conn., 1886. 

Annual Report on the State of the Asylum for the Relief of Persons Deprived of the Use of their 
Reason. Philadelphia, 1886. 

Report of the Managers of the State Lunatic Asylum, at Utica, for the year 1885. Albany, 1886. 

Report of the Metropolitan Throat Hospital for the Treatment of Diseases of the Nose and Throat. 
New York. 



The following Journals have been received in exchange : 



Annales de Dermatologie et de Sj'philigraphie. 

Annales de Gynecologie. 

Annales des Maladies des Organes Genito-Urinaires . 

Archives de Medecine et de Pharmacie Militaires. 

Archives de Neurologie. 

Archives de Tocologie. 

Archives Generates de Medecine. 

Bulletin Generale de Therapeutique. 

Gazette de Gynecologie. 

Gazette Hebdomadairede Medecine et de Chirurgie. 

Gazette Hebdomadaire des Sciences Medicales de 

Montpellier. 
Gazette Medicale de Nantes. 
Gazette Medicale de Paris. 
Journal de Medecine de Paris. 
L'Abeille Medicale. 
L'Encephale. 
Les Nouveaux Remedes. 
Le Progres Medicale. 
L' Union Medicale. 

Nouvelles Archives d'Obstetrique etde Gynecologie. 
Revue de Chirurgie. 
Revue de Medecine. 
Revue de Therapeutique. 
Revue des Sciences Medicales. 
Revue Generale d'Ophthalmologie. 
Revue Medicale Francaise et Etrangere. 
Revue Mensuelle de Laryngologie. 
The Asclepiad. 
Brain. 

Braithwaite's Retrospect. 
Bristol Medico-Chirurgical Journal. 
British Medical Journal. 
Dublin Journal of Medical Science. 
Edinburgh Medical Journal. 
Glasgow Medical Journal. 
Journal of Anatomy and Physiology. 
Journal of Physiology. 
Journal of Mental Science. 
Lancet. 

Liverpool Medico-Chirurgical Journal. 
London Medical Record. 
Medical Chronicle. 



Ophthalmic Review. 
Provincial Medical Journal. 
Practitioner. 

Australian Medical Journal. 
Indian Medical Gazette. 
Bibliothek fur Larger. 
Nordiskt Medicinskt Arkiv. 
Upsala Liikareforenings Fiirhandlingar. 
Kronika Lekarska. 

Annali Universali di Medicina e Chirurgia. 
Archivio di Orthopedia. 
Gazzetta degli Ospitali. 
Gazzetta Medica di Torino. 
La Medicina Contemporanea. 
La Rassegna. 
Giornale Italiano delle Malattie Venere e del la 

Pelle. 
L'Imparziale. 
Lo Sperimentale. 

Rivisita Internazionale di Medicina e Chirurgia. 
Gazette Medicale de TOrient. 
Correio Medico de Lisboa. 
Cronica Medico-Quirurgica de la Habana. 
Uniao Medica, Rio de Janeiro. 
Allgemeine wiener medizinische Zeitung. 
Archiv fur Gynecologie. 
Archiv fur klinische Chirurgie. 
Berliner klinische Wochenschrift. 
Centralblatt fiir Chirurgie. 
Centralblatt fiir Gynakologie. 
Centralblatt fiir klinische Medicin. 
Centralblatt fiir die medicinischenWissenschaften. 
Centralblatt fiir die gesammte Therapie. 
Deutsches Archiv fiir klinische Medicin. 
Deutsche medicinische Wochenschrift. 
Deutsche Zeitschrift fiir Chirurgie. 
Fortschritte der Medicin. 
Medicinisch-Chirurgisches Centralblatt. 
Medizinische Jahrbiicher. 
Monatshefte fiir praktische Dermatologie. 
Wiener medizinische Presse. 
Zeitschrift fiir klinische Medicin. 
Zeitschrift fiir physiologische Chemie. 



The usual list of American Journals has been received, 
prevented by lack of space. 



but their individual acknowledgment is 



CONTENTS. 



ORIGINAL COMMUNICATIONS. 

PAGE 

Perforating Inflammation of the Vermiform Appendix ; with Special 
Keference to its Early Diagnosis and Treatment. By Reginald H. 
Fitz, M.D., Shattuck Professor of Pathological Anatomy in Harvard 
University ............ 321 

Bacteriology. By W. Watson Cheyne, M.B., F.R.C.S., Assistant Sur- 
geon to King's College Hospital, London 346 

The Tendon-jerk and Muscle-jerk in Disease, and Especially in Posterior 
Sclerosis. By S. Weir Mitchell, M.D., Member of the National 
Academy of Sciences, and Morris J. Lewis, M.D., of Philadelphia . 363 

Insanity and Crime. By Richard J. Kinkead, M.D., Professor of Ob- 
stetric Medicine, and Lecturer on Medical Jurisprudence, Queen's Col- 
lege, Galway 373 

Keflex Aural Symptoms without Aural Disease. Aural Disease Exciting 
Reflex Symptoms. By C. J. Blake, M.D., Instructor in Diseases of 
the Ear, Harvard Medical Sctiool ; Aural Surgeon to the Massachu- 
setts Charitable Eye and Ear Infirmary; and T. M. Rotch, M.D., 
Instructor in Diseases of Children, Harvard Medical School ; Physician 
to the Boston Dispensary 384 

Yellow Fever ; its Transmission by Means of the Culex Mosquito. By 
Charles Finlay, M.D., Member of the Academy of Medical, Natural, 
and Physical Sciences of Havana, and of the " Sociedad de Estudios 
Clinicos" '. . .395 

The Local Treatment of Pseudo-membranous Croup : Intubation of the 
Larynx. By J. Lewis Smith, M.D., Clinical Professor of Diseases of 
Children in Bellevue Hospital Medical College, New York . . . 409 

Abnormal Visual Sensations. By F. R. Cross, M.B. Lond., F.R.C.S., 
Ophthalmic Surgeon to the Bristol Royal Infirmary, Surgeon to the 
Bristol Eye Plospital, etc 415 



312 CONTENTS. 

PAGE 

The Surgery of the Pancreas, as Based Upon Experiments and Clinical 
Researches. By N. Senn, M.D., Attending Surgeon to the Milwaukee 
Hospital ; Professor of the Principles and Practice of Surgery and of 
Clinical Surgery in the College of Physicians and Surgeons, Chicago, 
Illinois 423 

Castration in Mental and Nervous Diseases. A Symposium. By Sir T. 
Spencer Wells, Bart., late President of the Royal College of Surgeons 
of England ; Dr. Alfred Hegar, Professor of Obstetrics and Gyne- 
cology in the University of Freiburg; and Robert Battey, M.D., 
formerly Professor of Obstetrics in the Atlanta Medical College . . 455 



REVIEWS. 



The International Encyclopedia of Surgery. A Systematic Treatise on 
the Theory and Practice of Surgery, by Authors of Various Nations. 
Edited by John Ashhtjrst, Jr., M.D., Professor of Clinical Surgery 
in the University of Pennsylvania. Vol. VI 491 

Medicine of the Future. An Address prepared for the Annual Meeting 
of the British Medical Association in 1886. By Austin Flint (Senior), 
M.D., LL.D 495 

Dictionary of Practical Surgery, by Various British Hospital Surgeons. 
Edited by Christopher Heath, F.R.C.S., Plolme Professor of Clin- 
ical Surgery in University College, London ; Surgeon to University 
College Hospital ; Member of the Council and Court of Examiners of 
the Royal College of Surgeons of England 498 

Hyperalimentation in Phthisis. 

Die Uebernahrung bei der Lungenschwindsucht. Von Dr. E. Peiper, 

Greifswald. 
Hyperalimentation in Phthisis. By Dr. E. Peipee. 

Usvoyeniye i obmen azotistuikh veshchestv pri kormlenii chakhotoch- 

nuikh po sposobu Debove' a. By M. G. Kurloff. 
Assimilation of Nitrogenous Substances in the Hyperalimentation of 

Phthisis Patients by Debove's Method. By M. G. Kurloff . . 500 

The Modern Treatment of Stone in the Bladder by Litholapaxy. A 
Description of the Operation and Instruments, with Cases Illustrative 
of the Difficulties and Complications met with. By P. J. Freyer, 
M.A., M.D., Bengal Medical Service; Civil Surgeon, Mussoorie . . 504 



CONTENTS. 313 



PAGE 



Ueber die Topographischen Verhaltrisse des Genitale einer inter partum 
verstorbenen Primapara. Nach einem Gefrierschnitte gescliildert von 
Dr. H. Chiari, Professor der Pathologischen Anatomie an der deut- 
schen Universitat in Prag. 

On the Topographical Relations of the Genitals of a Primipara who died 
during Labor. Drawn from a frozen section by Prof. Chiari . . 506 

Practical Clinical Lessons on Syphilis and the Genito-Urinary Diseases. 
By Fessenden N. Otis, M.D., Clinical Professor of Genito-Urinary 
Diseases in the College of Physicians and Surgeons, New York . . 507 

Diseases of the Digestive Organs in Infancy and Childhood, with Chapters 
on the Investigation of Disease, and on the General Management of 
Children. By Louis Starr, M.D., Clinical Professor of Diseases of 
Children in the Hospital of the University of Pennsylvania, Physician 
to the Children's Hospital, Philadelphia, etc. ..... 509 

Peste de Cadeiras ou Epizootica de Marajo, suas analogies com o Beri- 
beri. Pello Dr. J. B. de Lacerda. 

Hip Pestilence, or Marajo Epizootic ; its Analogies with Beri-beri. By 
Dr. J. B. Lacerda 512 

Recent Works on the Care of the Insane. 

1. Handbook for the Instruction of Attendants on the Insane. 

2. How to Care for the Insane ; a Manual for Attendants in Insane 

Asylums. By William D. Granger, M.D., First Assistant 
Physician, Buffalo State Asylum for the Insane, Buffalo, N. Y. . 513 

Studies in Pathological Anatomy. By Francis Delafield, M.D., Pro- 
fessor of Pathology and Practical Medicine in the College of Physicians 
and Surgeons, New York. Volume II. Part 2 515 

Bright' s Disease, and Allied Affections of the Kidneys. By Charles W. 
Purdy, M.D., Queen's University, Professor of Genito-Urinary and 
Renal Diseases in the Chicago Polyclinic, etc. ..... 516 

A Manual of Practical Therapeutics. Considered with Reference to 
Articles of the Materia Medica. By Edward John Waring, CLE., 
M.D., F.P.C.P. London. Edited by Dudley W. Buxton, M.D., B.S. 520 

Vorlesungen Ueber Orthopsedische Chirurgie und Gelenkkrankheiten. 
Von Dr. Lewis A. Sayre, etc. Zweite, sehr erweiterte Auflage. Au- 
torisirte Deutsche Ausgabe. Von Dr. F. Dumont. 

Lectures on Orthopaedic Surgery and Joint Diseases. By Lewis A. 
Sayre. Authorized German edition, by Dr. F. Dumont, etc. . . 520 



314 CONTENTS. 



QUARTERLY SUMMARY 



OF THE 



PEOGEESS OF MEDICAL SCIENCE. 



ANATOMY. 



Under the charge of George D. Thane, M.R.C.S. Eng., 

Professor of Anatomy at University College, London. 



PAGE 

The Short Muscles of the Thumb and Little Finger. By H. St. John 

Brooks 521 

On the Central Connections of the Auditory Nerve. By Benno Baginsky 521 
On the Skin of the External Auditory Meatus. By E. Kauffmann . 522 
The Adenoid Tissue of the Pituitary Membrane. By E. Zuckerkandl . 522 
On the Position of the Pelvic Organs in the Female. By A. Waldeyer 
and J. Symington 522 



MATERIA MEDICA, THERAPEUTICS, AND 
PHARMACOLOGY. 

Under the charge of Roberts Bartholow, M.D., LL.D., 

Professor of Materia Medica, General Therapeutics, and Hygiene in Jefferson Medical College, Philadelphia. 



A New Alkaloid— Hydrochlorate of Tulipiferine. By Prof. J. M. Lloyd 

and Dr. Bartholow 524 

The Physiological Action of the Peptones and Albumoses. By Pollitzer 525 
Milk and its Therapeutical Applications. By Dujardin-Beaumetz . . 525 

Antipyrin. By Dr. Blanchard 527 

Treatment of Typhoid Fever by Corrosive Sublimate. By M. Greifenberger 527 
Another Method of Treating Typhoid. By Dr. Robin . . . .528 
Contribution to the Study of the Ferruginous Preparations employed 

Hypodermatically. By Dr. Hirschfeld 528 

The Use of Cocaine in the Treatment of Venereal Diseases. By Bono . 529 
Cataract caused by Naphthalan. By MM. Bouchard and Charrin . . 529 
The Consumption of Alcohol in France 529 



CONTENTS. 315 



PAGE 



Gelosin — A New Excipient and Vehicle. By Guerin .... 530 

Piliganine. By Dr. Bardet 530 

Salol, a New Antiseptic and Antirheumatic. By Dr. Sahli . . . 530 



MEDICINE. 

Under the charge of William Osler, M.D., F.R.C.P. Lond., 

Professor of Clinical Medicine in the University of Pennsylvania. 
ASSISTED BY 

J. P. Crozer Griffith, M.D., Walter Mendelson, M.D., 

Assistant to the Professor of Clinical Medicine in the Instructor in the Laboratory of the College of 

University of Pennsylvania. Physicians and Surgeons, JYeiv York. 



The Etiology and Curability of Pernicious Anaemia. By Keyher . . 531 
On the Operative Therapeutics of Basedow's Disease. By Hack . . 532 

Diabetic Hemiplegia. By E. Lepine and L. Blanc 532 

On the Pathology of Multiple Neuritis and Alcohol Paralysis. By Op- 

penheim 533 

Peripheral Neuritis in Phthisis. By MM. Pitre and Vaillard . . . 534 
An Unusual Form of Progressive Muscular Atrophy. By Charcot and 

Marie 534 

Streptococcus in Pneumonia after Typhoid Fever. By H. Neumann . 535 
Diseases of the Heart Resulting from Over-exertion. By Leydea . . 536 
Contributions to the Diagnosis and Therapeutics of Diseases of the 

Stomach. By Riegel 539 

On the Treatment of Gastric Ulcer with the Albuminate of Iron. By E. 

Gempt 541 

On the Diagnosis and Therapy of Perforative Peritonitis. By E. Wagner 541 
Chyluria with Chylous Ascites. By Professor Senator .... 542 
Improvement in the Use of Fehling's Solution. By I. Munk . . . 543 
Quantitative Determination of the Reducing Substances in Normal Urine. 

By Fliickiger, Salkowski, and I. Munk 544 

Albuminometry by Esbach's Method. By Esbach, Veale, and Guttmann 544 
Oxybutyric Acid in Diabetic Urine. By Stadelman .... 544 
Conditions Affecting the Presence of the Volatile Fatty Acids in the 

Urine. By von Jaksch 545 

A New Hsemometer. By von Fleischl 545 



316 CONTENTS. 



SURGERY. 



(IN EUROPE.) 

Under the charge of Frederick Treves, F.R.C.S. 

Surgeon to, and Lecturer on Anatomy at, the London Hospital. 



PAGE 

Recent Surgical Literature 545 

Fracture of the Patella. By C. Brunner and F. Treves . . . .548 
Compound Fracture of the Patella. By Mr. G. R. Turner . . .549 
On the Early Treatment of Prostatic Retention of Urine. By Mr. Buck- 

ston Browne ..... ....... 550 

Hypertrophy of the Prostate. By Sir Henry Thompson .... 550 

Hernia into the Foramen Qf Winslow. By Mr. Square .... 551 

Trephining for Intracranial Abscess. By Mr. Hulke .... 551 

Rest in the Treatment of Scrofulous Neck. By Mr. Treves . . .552 
Antiseptics. By Dr. Kummell, Dr. von Lesser, von Mosetig-Moorhof, 

Dr. Frankel, and Schmidt 552 

The Antiseptic Treatment of Erysipelas. By Dr. Haberkorn . . . 553 
Intestinal Obstruction due to Gall-stones. By Wising .... 553 
On Fractures and Dislocations. By Prof. Bruns and F. Miiller . . 554 
Treatment of Complicated Fractures of the Long Bones. By Bircher and 

Hausmann ............ 554 

Dislocation of the Radius with Fracture of its Head. By W. Wagner . 554 
Resection of a Cancerous (Esophagus. By Mikulicz .... 554 

Laryngectomy for Malignant Disease. By Dr. David Newman . . 555 
Toxic Symptoms from Cocaine. By G. Bockl and Schilling . . . 555 
On the Results of Operation for Cancer of the Lip. By A. Worner . 555 

Removal of Sebaceous Cysts. By Dr. C. Lauenstein .... 555 

The Treatment of Malignant New Growths with Arsenic. By F. Kobel, 

Spitzer, and Hermann . . . . 
Extirpation of Tumors of the Groin. By M. Kirmisson 
Cyst of the Pancreas. By F. Salzer 
Epithelioma of the Breast. By Prof. Czerny . 
Osteochondro-sarcoma of Breast. By Mr. Battle 
Abscess in the Antrum of Highmore. By Mikulicz and Ziem . . 557 

Tetanus. Bv Rosenbach .......... 558 



556 
556 
556 

557 
557 



(IN AMERICA. 



Supravaginal Amputation of the Uterus for Uterine Fibroids. By Dr. 

F. Lange 558 

Alexander's Operation By Dr. William M. Polk 559 



CONTENTS. 317 

PAGE 

Laparotomy for Suppurative Peritonitis. By Dr. E. J. Hall . . . 559 
Intubation of the Larynx. By Dr. Joseph O'Dvvyer and Dr. Frank E. 

Waxham 560 

On Fatty and Sarcomatous Tumors of the Knee-joint By Dr. Robert F. 

Weir 561 



OPHTHALMOLOGY. 

Under the charge of Charles Stepmax Bull, A.M., M.D., 

Lecturer on Ophthalmology in the Bellevue Hospital Medical College, Surgeon to the New York Eye and Ear 

Infirmary. 



Experimental Investigations of Intraocular Tension. By Holtzke . . 561 
Capsulectomy and a New Capsulectotome. By Telnikin .... 562 
The Physiological and Pathological Action of Cocaine. By Pfliiger . 562 
A Remarkable Case of Exophthalmos. By Motais ..... 563 
An Experimental Contribution to the Doctrine of Glaucomatous Excava- 
tion. By Laker 563 

Modified Sclerotomy in Cases of Corneal Staphyloma with Persistent 
Prolapse of the Iris By Inonye ........ 563 

Injections and Dressings of Eserine and Ocular Antisepsis. By Wecker 564 
Diagnosis of Simulated Unilateral Amblyopia. By Chauvel . . . 564 
On Latency in Cerebral Tumor — a Case of Relapsing Neuritis. By An- 
derson ............. 565 

The Excision of the Retrotarsal Folds and other Procedures for the Cure 

of Trachoma. By Hotz 565 

Irritable Stricture of the Urethra in the Male, Resulting from Masturba- 
tion, a Cause of Hyperesthesia of the Retina. By Beaver . . . 566 
Contribution to the Knowledge of Xanthopsia. By Thilbert . . . 566 
The Occurrence of Microorganisms in the Conjunctival Sac in Phlyctenu- 
lar Conjunctivitis and other Conditions of the Conjunctiva and Cornea. 

By Gifford \ .... 567 

Subconjunctival Lipoma in Connection with Ichthyosis Hystrix. By 

Bogel . ■ 568 

The Extraction of Intraocular Cysticerci. By Leber .... 568 
The Therapeutic Value of Laceration of the External Nasal Nerve. By 

Lagrange 569 

Studies on the Extraction of Cataract. By Bettremieux .... 569 



318 CONTENTS. 



OTOLOGY 



Under the charge of Charles H. Burnett, M.D., 

Professor of Otology in the Philadelphia Polyclinic and College for Graduates in Medicine, etc. 



Acute and Chronic Purulent Inflammations of the Middle Ear Tract and 
their Complications. By Dr. Samuel Sexton 569 

A New Operation for the Kadical Cure of Chronic Purulent Inflamma- 
tion of the Middle Ear Tract. By Dr. Sexton 570 

Suppuration of the Tympanic Cavity Treated with Instillations of Corro- 
sive Sublimate Solutions. By Dr. Dujardin 571 

Trephining for Evacuation of Intracranial Abscess Occurring in Connec- 
tion with Suppurations in the Ear. By Mr. J. W. Hulke . . . 571 

Certain Technical Details Relating to Operations on the Mastoid. By 
Dr. A. H, Buck .574 

Epileptiform Attacks Caused by Simple Chronic Non-suppurative Otitis 
Media. By Dr. Noquet 576 

Tinnitus Auriuin in Affections of the Stomach. Bv Dr. E. Meniere . 576 



DISEASES OF THE LARYNX AND CONTIGUOUS 
STRUCTURES. 

Under the charge of J. Solis-Cohen, M.D., 

Professor of Diseases of the Tliroat and Chest, Philadelphia Polyclinic. 

Treatment of Diphtheria by Fumigations of Coal Tar and Turpentine. 

By M. Cadet de Gassicourt 577 

The Nasal Douche. By Dr. E. J. Moure 578 

The Relation of Diseased Nasal Mucous Membrane to Asthma. By M. 

Bresgen, W. Lublinski, and Dr. Bocker ....... 578 

Intranasal Disease and Exophthalmic Goitre. By Prof. Hack . . 580 

Hay Fever. By Dr. Beverly Robinson . . . . . . . 580 

Tuberculosis of the Larynx. By Prof. Massei 581 

Lactic Acid as a Curative Agent in Tuberculous Ulcerations of the Larynx. 

By Dr. Hering 581 

Tuberculous Tumors of the Larynx. By Dr. Percy Kidd . . . 581 
Spasm of the Larynx and Epilepsy. By Prof. H. Widerhofer . . 582 

Laryngeal Neuroses of Central Origin. By Dr. H. Krause . . . 582 
Laryngeal Paralyses. By Drs. J. Charazac, F. H. Hooper, and J. Solis 

Cohen 584 

Feeding by the Stomach-tube after Tracheotomy. By Mr. S. Herbert 

Habershon 585 

Laryngectomy. By Dr. J. Baratoux ....... 585 



CONTENTS. 319 



DERMATOLOGY. 

Under the charge of Louis A. Duhring, M.D., 

Professor of Dermatology in the University of Pennsylvania, 
AND 

Henry W. Stelwagon, M.D., 

Physician to the Philadelphia Dispensary for Skin Diseases. 



PAGE 



Hydroa. By Crocker 586 

A Case of Lichen Planus. By Finny 587 

Cases of Orbital Nsevi Treated by Electrolysis. By Snell . . . 587 
The Relation of Lupus Vulgaris to Tuberculosis. By Max Bender . 587 

Molluscum Contagiosuni — an Analysis of Fifty Cases. By Allen . . 588 
Notes upon Lanolin. By G. H. Fox, W. G. Smith, and Liebreich . . 590 



MIDWIFERY. 

Under the charge of Francis H. Champneys, M.B., F.R.C.P. 

Obstetric Physician to St. George's Hospital. 



Palpation of the Uterus per Vaginam. By Sanger 590 

Case of Twins Occupying a Common Amniotic Cavity in which the Cords 

were Interlaced and Coiled Round Foetal Parts. By Sedlaczek . . 591 
Pregnancy in One Horn of Uterus Bicornis ; Retention of the Mature 

Foetus; Removal of the Pregnant Horn. By Wiener .... 591 

On Adenoma of the Placenta. By Klotz ...... . 592 

On Habitual Death of the Foetus in Utero due to Renal Disease in the 

Mother. By Fehling 592 

Hydrastis Canadensis does not Induce Uterine Contractions. By Schatz 593 

On the Etiology of Face Presentations. By Schatz 593 

Injuries of the Vagina and Perineum Accompanying Labor. By Freund 593 
Prolapse of the Umbilical Cord through the Rectum. By Stroynowski . 594 
On the Continuous Catgut Suture in Cases of Ruptured Perineum. By 

Keller 595 

On the Application of the Forceps to the After-coming Head. By 

Freudenberg 595 

Recent Improvements in the Performance of Csesarean Section. By 

Sanger 596 

The Etiology of Puerperal Mastitis. By Bumm 597 

On the Elimination of Various Substances through the Milk. By Fehling 598 
How can most Air be Made to Pass in and out of the Chest of Children 

Born in a State of Asphyxia. By Lahs 599 

On the Value of Schultze's Swinging Movements for Resuscitating Ap- 
parently Stillborn Children. By Skutsch 599 

Some Remarks on Infant Feeding. By Dr. Henry Ashby . . . 600 



320 CONTENTS. 



GYNECOLOGY 



On the Suppuration and Discharge into Mucous Cavities of Dermoid 
Cysts of the Pelvis. By Mr. G. E. Herman 601 

On Some Forms of Endometritis Corporis. By Lohlein .... 601 

On Castration in Cavernous Myofibroinata of the Uterus. By Dr. Golden- 
berg 603 

On the Indications for the Site of the Operation in Cancer of the Cervix 
Uteri. By M. Hofmeier and Dr. Brennecke 604 

On Extirpation of the Entire Uterus. By Dr. W. A. Duncan . . 607 



MEDICAL JURISPRUDENCE AND TOXICOLOGY 

Under the charge of Matthew Hay, M.D., 

Professor of Medical Jurisprudence, University of Aberdeen. 

Three Cases of Injury of the Heart. By Dr. Schulte . . . .608 

Murder or Suicide ? By Freyer ........ 609 

Case of Alleged Infanticide. By Kob ....... 610 

Antisepsis in Relation to Legal Responsibility. By Dr. Carl Deneke . 611 
The Changes which the Different Mercurial Salts undergo in the Organ- 
ism. By Fleischer ........... 611 

Coal-gas Poisoning. By Warfvinge . 612 

Toxic Action on the Lower Fatty Acids. By Heinrich Mayer . . 612 

The Cause of the Toxic Action of Chlorate of Potassium. By Stokvis . 613 
Effects of Drastic Poisons on the Intestinal Tract. By Lucien Butte . 613 
The State of the Corpse after Poisoning by Arsenic. By Prof. Zaaijer . 614 
Injury to the Head. By Jaumes ........ 615 



PUBLIC HEALTH. 

Under the charge of Shirley F. Murphy, M.R.C.S. 



Milk Infection 615 

Lead Poisoning. By Reichardt and Dr. Sinclair White .... 617 

Industrial Diseases. By Bruhat, Dr. B. W. Richardson, F. Schiiler, M. 
Raymondaud, and Dr. Boudet ........ 618 

Precautions against Infectious Diseases in Schools. By Dr. Annsperger 619 



THE 

AMERICAN JOURNAL 

OF THE MEDICAL SCIENCES 

OCTOBER, 1886. 



PERFORATING INFLAMMATION OF THE VERMIFORM 
APPENDIX ; 

WITH SPECIAL REFERENCE TO ITS EARLY DIAGNOSIS AND TREATMENT. 1 

By Reginald H. Fitz, M.D., 

SHATTUCK PROFESSOR OF PATHOLOGICAL ANATOMY IN HARVARD UNIVERSITY. 

It appears that even the most recent systematic writers are by no means 
agreed as to the exact relation of inflammation of the csecum and that 
of the appendix to peritonitis and perityphlitis. The vital importance 
of the timely and appropriate treatment of the disease in question is 
becoming more and more apparent. Such treatment is often postponed 
till hopeless, even if its application is at any time entertained. It was, 
therefore, to be anticipated that the critical consideration of a large 
number of unquestionable cases of perforation of the csecal appendix 
might serve to make prominent the features essential for diagnosis and 
treatment. 

In 1834, James Copland, in his Dictionary of Practical Medicine, 2 
first discriminated between inflammations of the caecum, the vermiform 
appendix, and the pericecal tissue. Isolated cases of fatal inflammation 
of the appendix had been published from time to time before this date. 
Their importance did not become well recognized, however, till after 
Dupuytren's views had been made known concerning the relation of the 
csecum to the production of what had hitherto been termed iliac abscess, 
or phlegmon of the iliac fossa. At the instigation of this eminent sur- 
geon, Husson and Dance 3 published an article on the subject, apparently 

1 Read before the Association of American Physicians, June 18, 1886. 

2 Vol. i. p. 277. s Repertoire Gen. d'Anat., etc., 1827, iv. 154. 

NO. CLXXXIV. — OCTOBER, 1886. 21 



322 FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 

expressing his ideas. These were subsequently personally presented by 
him in his Lectures on Clinical Surgery} 

In consequence of the interest thus aroused, Goldbeck, 2 at the sugges- 
tion of Puchelt, of Heidelberg, wrote his graduation-thesis upon the 
same subject. He adopted the views of the French writers, and applied 
the term perityphlitis to the disease described. His essay contains the 
report of a case of perforation of the appendix and associated peritonitis. 
But he regards it as one of fecal retention, and as quite distinct from the 
perityphlitis or inflammation of the connective tissue around the caecum. 
He states that in fatal cases of the latter affection the appendix has been 
found intact. 

Of the various names connected with the early history of the disease 
under consideration that of John Burne, Physician to the Westminster 
Hospital, deserves particular mention. In the first 3 of two admirable 
articles separated by an interval of two years, he calls attention to the 
material difference in the character of inflammation of the appendix and 
that of the caecum. He attributes this difference to the peculiar con- 
formation and situation of the former. His second paper 4 contains an 
additional number of cases of affections of the caecum and appendix, a 
criticism of the opinions of the French writers, and a reiteration of his 
own views with such modifications as a more extended experience per- 
mitted. The name tuphlo-enteritis is offered as an equivalent for inflam- 
mation and perforative ulceration of the caecum and of the appendix. 

In the interval between the publication of the above-mentioned arti- 
cles Albers 5 contributed a paper on inflammation of the caecum. He 
first introduces the term typhlitis, and discriminates between acute, 
chronic, and stercoral typhlitis and perityphlitis. He charges Puchelt 
and foreign writers with confounding the last affection with the acute 
and stercoral varieties of typhlitis. The frequent termination of the 
perityphlitis in abscess is recognized, likewise the possibility of commu- 
nication between the pus-cavity and that of the appendix or caecum. 
This communication he regards as secondary. He says, 6 " It is not at 
all clear just why the processus vermiformis should be so often affected, 
for in this disease perforation of the caecum should be far more likely 
than that of the appendix." 

Although the term perityphlitis thus became synonymous with inflam- 
mation of the pericaecal tissue, the tendency was inevitably toward the 
recognition of a somewhat similar clinical picture and a different ana- 
tomical seat. Oppolzer 7 discriminated between cases of perityphlitis 

i Lerons Orales de Clin. Chir., 1833, iii. 330. 

2 Ueber eigenth. entz. Geschw. i. d. rechten Hiiftbeingegend, 1830. 

3 Med. -Chir. Trans., 1837, xx. 219. * ibid., 1839, xxii. 33. 
5 Beob. auf d. Geb. d. Path, und Path. Anat., 2ter Theil., 1838, 1. 

e Op. cit., p. 19. " Allg. Wiener ined. Zeitung, 1858, xx. 81 ; xxi. 8G. 



FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 323 

where the inflammation was situated in the connective tissue about the 
caecum, and others where the inflammatory swelling lay between the iliac 
fascia and the bone. These were further distinguished from cases of en- 
cysted peritonitis in this region, and from perforation of the appendix. 
The latter was stated to be always productive of a circumscribed peri- 
tonitis, except when the perforation took place through the adherent 
peritoneum. Then both peritonitis and inflammation of the subperitoneal 
tissue would occur. The anatomical seat of the inflammatory process 
was thus further complicated. Oppolzer suggested the term paratyph- 
litis, which, according to Eichhorst, 1 represents an inflammation of the 
connective tissue behind the caecum, while perityphlitis designates an 
inflammation of the peritoneal coat of the caecum and appendix. 
Typhlitis is applied to an inflammation of the aj3pendix and of the 
caecum. Whittaker 2 uses the same definitions, while Ziegler 3 applies the 
term typhlitis to inflammation of the vermiform appendix, and perityph- 
litis to that of the parts in its vicinity. 

The clinician obviously recognizes as of the chiefest importance the 
parts to which local treatment may be directly applied. His attention 
is thus conspicuously directed to the caecum, which may be evacuated, or 
to the perityphlitic abscess, which may be emptied. The pathologist 
looks for the seat and causes of the disease, and finds that in most fatal 
cases of typhlitis the caecum is intact, while the appendix is ulcerated 
and perforated. He sees that the so-called perityphlitic abscess is 
usually an encysted peritonitis. Furthermore, if an abscess exists in 
the pericaecal fibrous tissue, it is in most instances caused by an inflamed 
appendix. Finally, if the encysted peritoneal abscess, or the abscess in 
fibrous tissue behind the caecum, does communicate with the latter, such 
an opening is usually the result, not the cause, of this abscess. 

With, 4 influenced by the predominant importance of the independent 
consideration of inflammation of the appendix and its results, uses the 
term appendicular peritonitis to indicate the perityphlitis proceeding 
from disease of the appendix. As a circumscribed peritonitis is simply 
one event, although usually the most important, in the history of in- 
flammation of the appendix, it seems preferable to use the term appen- 
dicitis to express the primary condition. This may terminate as an 
appendicular peritonitis or as a paratyphlitis. In like manner the rare, 
primary, perforating typhlitis (caecal perforation) may be followed by a 
perityphlitis — that is, an encysted peritonitis about the caecum, or by a 
paratyphlitis. The perityphlitic abscess of the surgeon, when seen 
early, is thus usually an encysted peritonitis of appendicular origin. 
More rarely, at this date, it may be the result of a suppurative para- 

1 Handb. d. Spec. Path, und Therap., 2ter Aufl., 1885, ii. 188. 

2 Pepper's System of Pract. Med., 1885, ii. 814. 3 Lehrb. d. Path. Anat., 4te Aufl., 1885., ii. 1. 
4 Xordiskt Med. Ark., vii. 1. London Med. Kecord, 1880, viii. 213. 



324 FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 

typhlitis. The causes of this last affection are numerous and by no 
means confined to the appendix or caecum, although a perforating in- 
flammation of each of these parts of the intestinal tract may act as a 
cause. 

Any attempt at explaining the various results of an inflammation of 
the appendix, must necessarily be preceded by a statement of the pecu- 
liarities it may present, with respect to structure and position. These 
peculiarities, though in part of congenital origin, in most instances bear 
evidence of having been acquired as the result of previous disease. This 
statement, based upon a long personal experience, is more than con- 
firmed by the observations made elsewhere. Matterstock 1 states that 
Tiiugel, during a period of two years at the Hamburg Hospital, found 
30 instances of partial or complete obliteration of the appendix, 43 cases 
of catarrh and fecal concretions, 12 of abnormal adhesions, and 11 of 
tuberculous ulcers. All these in addition to perforations, and despite 
the fact that attention was not invariably directed to such peculiarities. 
Toft, as referred to by With, 2 found the appendix diseased in 110 out of 
300 post-mortem examinations, every third person thus possessing a dis- 
eased appendix. 

Personal observations have enabled me to recognize considerable 
variations in the length of the appendix, the longest being nearly six 
inches. Wister 3 alludes to one which was nine inches long. It is fre- 
quently seen with an attached fold of peritoneum and fat tissue, suggest- 
ing an omentum or mesentery. Its free end has been found in the iliac 
fossa, as well as behind the caecum ; along the brim of the pelvis and 
hanging into the cavity of the latter. Irregular positions have often 
been associated with fibrous adhesions. The appendix has been found 
thus attached not only in the places above mentioned, but also with its 
tip directed upward and its course more or less parallel with that of the 
caecum, either behind, to the right, or to the left of this structure. It has 
also been found adherent to the- mesentery with its tip bent at right 
angles and lying between the appendix and this structure. Kraussold 4 
observed its course directed upward and backward, forming a loop 
around the ileum with its tip directed forward. It has been seen 
pointing outward, then forward, formiDg a loop around the lower end 
of the caecum with its tip behind the latter. 

Firket 5 records the adherence of the appendix to the ileum through- 
out the length of the former, with a communication between the cavities 
of the two and without an evident ulceration of the mucous membrane. 
Adherence to the rectum w r ith a communication between the cavities of 



i Gerhardt's Handb. d. Kinderkrankh., 1880, iv. 2, 897. 2 Loc. cit. 

3 Trans. Coll. Phys. Philada., 1856-62, N. S., iii. 147. 

4 Volkmann's Samml. klin. Vortr., 1881, cxci. 1707. 

5 Ann. d. 1. Soc. Med.-Chir. d. Liege, 1882, xxi. 58. 



FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 325 

each is recorded. 1 Adhesions of the tip to the mesentery, the rectum, 
and bladder are frequent. Its presence in a hernial canal led Shaw 2 to 
suspect a disease of the testicle. Thurmann 3 records a like occurrence, 
and the formation of a scrotal tumor as large as the two fists in conse- 
quence of an inflammation of the appendix. Its tip has been found 4 
adherent to the abdominal wall in the vicinity of the navel, and pus has 
been discharged from it at this point. 

Complete or partial obliterations of the canal are frequent. In the 
former instance a solid cord results. In the latter, a considerable cystic 
dilatation of the tip may follow ; or a funnel-shaped pouch at the origin 
is often associated with obliteration of the remaining portion of the 
tube. 

These variations in length, position, and patency, whether congenital 
or acquired, are of obvious importance in explaining many of the 
apparent differences in the clinical histories of typhlitis and perityph- 
litis. Their significance in the etiology of appendicitis will appear 
directly. 

The frequent presence of foreign bodies in the canal of the appendix 
is of well-known occurrence. These are a variety of seeds, especially of 
fruit. Less common are hairs, particularly bristles, worms or their 
eggs, shot, pins, pills, and gall-stones. By far the most numerous are 
moulded masses of inspissated feces, more or less cylindrical in shape 
and of extreme variation in density. Some are of the consistency of 
normal excrement, while others are of stony hardness in consequence of 
their infiltration with earthy salts. The relative frequency of their 
presence in the appendix is manifested by the records of fatal cases of 
appendicitis, but their actual frequency far exceeds the number of these 
cases. In my own experience it is rather the rule than the exception 
for the appendix to contain moulded, more or less inspissated feces. 

The frequency of such retention may be due to the congenital or 
acquired peculiarities of the appendix already described. German 
writers attach a certain importance to the presence of a valve-like pro- 
jection of mucous membrane, discovered by Gerlach, 5 at the mouth of 
the appendix. Although a pinhole opening may result, any consider- 
able obstruction must be of extreme rarity. The habits of individuals 
with reference to diet and regulation of the bowels are of unquestioned 
importance. Equally significant is the controlling fact, that most per- 
sons suffering from habitual constipation and accustomed to swallow the 
seeds of fruit, escape inflammation of the appendix. 

Recognizing the lack of agreement in the use of the terms typhlitis 
and perityphlitis, a collection has been made of 257 cases of perforating 

i Trans. Lond Path. Soc, 1876, xxvii. 161. 2 nnd., 1848, i. 270. 

3 Prov. Med. and Surg. Journ., 1848, 477. 4 Lancet, 1839-40, ii. 565. 

5 Zeitschr. f. rat, med., 1847, vi. 12. 



326 FITZ, INFLAMMATION OF VEEMIFORM APPENDIX. 

inflammation of the appendix. By limiting the attention to the essen- 
tial features of these cases, it was thought possible to recognize the char- 
acteristics of this sharply defined affection, by means of which it might 
be differentiated from all others occurring in this region. At the same 
time a comparison is drawn between many of these characteristics and 
those occurring in cases of typhlitis and perityphlitis. The latter terms 
are sufficiently indicative of a clinical picture, although its seats and 
causes suggest the importance of shades of distinction ; 209 of these cases 
have been collected, and serve as the basis of a series of tables to be 
contrasted with those obtained from the analysis of the 257 cases of 
appendicitis. 

The etiological importance of the presence of fecal masses and of foreign 
bodies in the production of inflammation of the appendix is well recog- 
nized. Matterstock 1 found in 169 cases of fatal perforating appendicitis 
that fecal concretions were present in 53 per cent., and foreign bodies in 
1 2 per cent. In the series here collected, out of 152 cases the percentage 2 of 
fecal masses was 47 per cent., that of foreign bodies 12 per cent. It thus 
appears that in nearly one-half of the cases more or less inspissated feces 
were found, and that in nearly one-eighth of the series foreign bodies 
other than feces were present. Thus, in about three-fifths of all cases of 
perforating inflammation of the appendix either dried feces or foreign 
bodies were present in the tube. When seeds are stated to have been 
found, the evidence is not always sufficient to exclude the possibility of 
a mistake having been made as to the nature of the foreign body. Not- 
withstanding this large percentage the reality is undoubtedly much 
greater. Many are overlooked at the time of making the examination, 
others are macerated in the contents of the abscess. Still others, perhaps, 
escape with the pus, which makes its way outward through the various 
channels by which the abscess may communicate with the surface of the 
body. 

The frequent immunity of the appendix from inflammation in the 
presence of inspissated feces and foreign bodies suggests the importance 
of other factors in the etiology. External violence is occasionally 
recorded as an immediate precursor of the attack. Among the 257 
cases were 19 who were supposed to have received an injury, the result 
rather of indirect than of direct violence: from lifting a heavy weight 
in 9 instances, and from a fall or blow in 10. Among 209 cases of typh- 
litis and perityphlitis external violence immediately preceded the attack 
of the disease in 10 per cent. 

Digestive disturbances are of obvious importance in the etiology of 
inflammation of the appendix, since this organ is a part of the alimentary 
canal. There were 15 instances of prolonged constipation, 9 of diarrhoea, 

1 Op cit. - In general whenever percentages are given, fractions will be disregarded. 



FITZ, INFLAMMATION OF VEEMIFOEM APPENDIX." 327 



and 6 of vomiting. The attacks of diarrhoea and vomiting were usually 
the result of indiscretion in diet, but they were sometimes occasioned by 
the use of domestic remedies. These were administered for the relief of 
constipation or other disturbances attributed to a sluggish action of the 
stomach and bowels. 

Among the cases of typhlitis and perityphlitis were 38 of constipation, 
15 of diarrhoea, and 3 of vomiting ; these symptoms being of apparent 
etiological importance. 

Notwithstanding the frequency of typhoid fever and of intestinal 
tuberculosis, in which affections the mucous membrane of the appendix 
is often diseased, a resulting perforation seems to have been relatively 
infrequent. There were 8 of perforating ulcer of the tuberculous ap- 
pendix, and 3 of this lesion in convalescence from typhoid fever. 

Among the 209 cases of typhlitis and perityphlitis were 2 occurring 
in tuberculous persons. 

The consideration of sex in 247 cases gives the following result : 197 
males, 80 per cent., and 50 females, 20 per cent. These percentages are 
the same as those found by Fen wick 1 in the analysis of 130 cases. 

In 209 cases of typhlitis and perityphlitis there were 156 males, and 
53 females ; 74 per cent, of the former, and 26 per cent, of the latter. 

The age in 228 cases of appendicitis is recorded as follows : 
From 20 months to 10 years 



" 10 


pears 


' 20 


" 20 


" 


' 30 


" 30 


u 


' 40 


" 40 


u 


' 50 


" 50 


a 


' 60 


" 60 


u 


" 70 


" 70 


" 


' 78 



22 


= 


10 


per 


cent. 


. 86 


= 


38 




et 


. 65 


= 


28 




a 


. 34 


= 


15 




a 


. 8 


= 


3 




u 


. 11 


= 


5 




a 


. 1 


= 


i 




U 


. 1 


= 


i 

2 




ci 



The age of the youngest patient was 20 months, that of the oldest, 78 
years ; 173 cases, 76 per cent, of the entire list, were under the age of 30 
years, and nearly 50 per cent, were under the age of 20 years. Fen- 
wick's 2 table of ages is based upon the consideration of 97 cases, and 
shows smaller percentages for the several decades up to the age of 40 
years. 

The age of the patient in 178 cases of typhlitis and perityphlitis was : 
From 4 years to 10 years 



" 10 " 


" 20 


" 20 " 


" 30 


" 30 " 


'' 40 


« 40 « 


" 50 


" 50 " 


" 60 


" 60 " 


" 70 


" 70 " 


" 78 



10 


= 


6 per cent 


53 


= 


30 


53 


= 


30 


25 


= 


14 


18 


== 


10 


10 


= 


6 


7 


= 


4 


2 


= 


1 



Lancet, 1884, ii. 987, 1039. 



2 Loc. cit. 



328 FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 

From the above consideration it is apparent that perforating appen- 
dicitis is a disease most frequently occurring among healthy youths and 
young adults, especially males. Further, that attacks of indigestion and 
acts of violence, particularly from lifting, jumping, and falling, are 
exciting causes in one-fifth of the cases. A local cause is to be found 
in more than three-fifths of all cases in the retention in the appendix of 
more or less inspissated feces, or in the presence there of a foreign body. 
The retention of feces may be promoted by a constipated habit, but con- 
genital or acquired irregularities in the position and attachments of the 
appendix frequently act as favoring causes. A fact in support of the 
last-mentioned statement is to be found in the frequency of successive 
attacks, one or more, of inflammation of the appendix. Among 257 
cases were 28, 11 per cent., which presented similar symptoms of greater 
or less severity, at various intervals before the final attack. Recurrence 
is mentioned in 23 out of 209 cases, again 11 per cent., of typhlitis and 
perityphlitis. 

The inflammatory process once excited, its course and results show 
extreme variations. A simple catarrhal appendicitis is to be recognized 
anatomically, but it is doubtful whether its clinical appreciation is pos- 
sible. This appendicitis, in the absence of a concretion or foreign body, 
may progress toward ulceration, even to a peritonitis, which may termi- 
nate fatally. In the presence of a foreign body or concretion these 
events are of likely occurrence. On the one hand, the inflammation 
may result in the more or less complete obliteration of the canal of the 
appendix, with or without circumscribed dilatation. On the other, the 
ulcerative process becomes associated with a necrosis of the wall, a peri- 
tonitis, usually circumscribed at the outset, and perforation. In those 
cases where the appendicular peritonitis represents the extension of an 
inflammation through the wall of the appendix without perforation, 
permanent adhesions of the appendix to neighboring parts remain as 
evidence of the process. When it is associated with necrosis of the wall, 
the inflammation of the peritoneal coat tends to become diffused and 
productive of serous and cellular exudations. The adherence of coils of 
intestine to each other and to the abdominal wall favors the accumula- 
tion of the exudation in a limited space, and thus the formation of the 
tumor. At this stage the anatomical condition is a circumscribed peri- 
tonitis, the appendicular peritonitis of With. In certain instances the 
term perityphlitis might be applied in an exact anatomical sense, as the 
peritoneal inflammation frequently extends to the serous investment of 
the lower part of the caecum. But in the last two cases of fatal appen- 
dicitis examined by me, the appendicular peritonitis was wholly pelvic. 
The changes observed in the appearance of the serous covering of the 
caecum were of the same character as those affecting the peritoneum 
elsewhere. This peritoneal abscess may then become absorbed, or its 



FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 329 



contents may escape into the general peritoneal cavity through ruptured 
or softened adhesions. In the latter event, as a rule, death rapidly 
follows. The exceptional case reported by Markoe 1 may be regarded as 
one of extreme rarity. A child with symptoms of general peritonitis 
on the second day, died a month later from another disease. The 
appendix had been perforated and the intestines were adherent in 
different places. 

The product of the circumscribed peritonitis varies exceedingly in 
quality and quantity. Although it is usually thin, discolored, and very 
offensive, it may be thick, yellowy and odorless. In the post-mortem ex- 
amination of a case of recent occurrence, where general peritonitis was 
the cause of death, the abscess contained perhaps an ounce of pus. The 
peritonitis was the result of a secondary mesenteric thrombophlebitis, 
while the primary appendicular peritonitis was apparently in a retro- 
grade condition. The acute stage of the disease lasted more than six 
weeks. Barrett 2 states that he removed from a perityphlitic abscess, on 
the sixty-second day, more than a gallon of pus, liquid feces, and scy- 
bala. The presence of the last element indicates a communication with 
the large intestine. 

If the case does not terminate as thus stated, the tumor may suddenly 
diminish in size with the discharge of pus from a hollow organ, as the 
intestine, bladder, or vagina. The anterior abdominal w ; all may become 
perforated and a sinus be established opening in the groin, lumbar 
region, or at the umbilicus. Shaw 3 mentions the occurrence of multiple 
abscesses of the scrotum from a perforated hernial appendix, and Thur- 
mann 4 records a similar instance. Such sinuses often remain open for a 
long time, even many years. Through the kindness of Dr. A. T. Cabot, 
of Boston, I saw a patient with a fecal fistula which had existed for nine- 
teen months. At the outset a tender swelling in the right groin had 
been incised, but the wound never healed. After an operation to pro- 
mote the healing of the sinus, about an inch of the perforated appendix 
protruded from the wound. A similar protrusion had taken place six 
months earlier. The outer surface of the appendix was smooth, of a 
dusky red color, and the margin of the opening was sharply defined. 
Pressure upon the abdominal wall over the csecum caused soft, yellow 
intestinal contents to appear in the wound. 

The abscess may contain sloughs of tissue and yet be intraperitoneal. 
In a recent post-mortem examination I removed from the encysted 
abscess around the appendix a slough, three inches in length, repre- 
senting the detached peripheral portion of the tube. Ballou 5 records 
a case where the sloughed appendix was discharged per anum, the 

i Am. Med. Monthly, 1857, viii. 231. 2 Va. Med. Monthly, 1875-76, ii. 120. 

3 Loc. cit. * Loc. cit. 

5 Trans. R. I. Med. Soc, 1877-82, ii. 418. 



330 FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 



patient recovering. In the case reported by Pooley, 1 apparently the 
entire appendix escaped as a slough from the wound. 

The more protracted the course of the disease the greater is the 
probability of the destruction of the peritoneum forming the wall of the 
abscess. With the perforation of the parietal peritoneum may occur 
extensive necrosis, purulent and fecal infiltration of the abdominal 
walls. Within three weeks the iliac muscle may be destroyed and the 
ilium be bared. The course of the psoas and iliacus may be followed 
into the thigh, and extensive and deep-seated destruction of tissue with 
fecal infiltration be present in this region. The pus may extend through 
the obturator foramen, forming a deep-seated abscess of the hip and 
thigh, and may enter the hip-joint. 

Moore 2 has shown that disease of the hip-joint may follow perityphlitis, 
and Gibney 3 has called attention to the possibility of mistaking cases of 
perityphlitis for disease of the hip-joint. The primary appendicular 
peritonitis may in like manner be continued into the tissues behind the 
csecum, and thus a secondary paratyphlitis or perityphlitic abscess be 
occasioned. So various are these possibilities that every case of so-called 
perityphlitic abscess must be regarded as primarily one of a perforating 
appendicitis unless proven to be the contrary. 

With the frequent eventual destruction of the peritoneal wall of the 
abscess is the possibility of death from hemorrhage. Conant 4 describes 
the case of a young man who died at the end of three weeks. There 
was no general peritonitis, but the abscess communicated with the csecum 
(the appendix being destroyed) and held a pint of clotted blood. Fatal 
hemorrhage from ulceration of the deep circumflex iliac artery is 
recorded by Bryant. 5 This case is not unlikely to have been one of 
appendicitis, although the condition of the appendix is not stated. Again, 
Powell 6 reports a case where the appendix was adherent to the internal 
iliac artery, the cavities of the two being in communication. The colon 
and caecum were distended with gas and dark blood. 

The occurrence of disease of remote parts may be alluded to, as 
abscesses of the liver from pylephlebitis or portal embolism in conse- 
quence of a mesenteric thrombophlebitis near the appendix. The 
affection of the liver and portal vein may be the result of a direct 
continuance of the phlebitis, or may follow putrid embolism from a 
thrombus in the immediate vicinity of the appendix. The extension of 
a secondary paratyphlitis may cause perforation of the diaphragm with 
a consecutive pleurisy or pericarditis. 

In considering the symptoms of appendicitis, it is to be noted that 
attacks of inflammation frequently occur without giving rise to any 

1 N. Y. Med. Record, 1875, x. 267. 2 Lancet, 1864, ii. 514. 

3 Am. Joitrn. Med. Sci., 1881, lxxxi. * Am. Med. Monthly, 1858, x. 359. 

5 British Med. Journ., 1884, ii. 43. 6 N". 0. Med. and Surg. Journ., 1855, xi. 468. 



FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 331 

characteristic symptoms, and often without a suggestion of any distinct 
malady. 

A comparison of the results of post-mortem examinations with the 
records of the previous histories of patients justifies this statement, 
unless it be urged that the disease occurred so early in life as to have 
been unappreciated or forgotten. Out of 227 cases of perforated 
appendix, however, 22, about 10 per cent., were under the age of ten 
years. This number is far too small to account for the occurrence of 
evidences of disease of the appendix in more than one out of every three 
autopsies. 

The records of the Massachusetts General Hospital state that an 
individual with an appendix a half inch long, thickened, curved, and 
intimately adherent to the thickened and opaque subjacent peritoneum, 
never had symptoms of inflammation in this region. Another patient 
was never sick before his fatal illness, although the appendix and csecum 
were closely united to the neighboring parts by old fibrous adhesions, 
and the canal of the appendix was obliterated. Still another patient 
was always well and strong till within eleven days of his death, yet the 
appendix was converted into a solid fibrous band intimately united by 
firm adhesions to the posterior wall of the caecum. The severity of 
these lesions suggests the probability that apparently slight disturb- 
ances of digestion were overlooked. The diarrhoea, constipation, or 
abdominal pain, especially when occasionally recurrent, were, regarded 
as characteristic of a feeble digestion. There can be but little doubt 
that a diagnosis of bilious attack, colic, gastritis, enteritis, gravel, 
ovaritis, congestion of the womb and the like, may not unfrequently 
conceal the existence of an inflamed appendix. 

The latency of the symptoms in certain cases of appendicitis is such 
that the eventual diagnosis is obscured, and the desirable method of 
treatment hopelessly postponed. Buck * reports that a sailor was at 
work rolling barrels of flour till the day of his admission to the hospital. 
He then had a prominent iliac tumor extending along the outer half of 
Poupart's ligament. Fluctuation was transmitted from it to below the 
inner half of the ligament. Another sailor left Portland for New York, 
April 12, 1886, and arrived five days later. In the meantime he purged 
himself in consequence of a right iliac pain. Although suffering, he kept 
at work during the following week. He then left for Boston, where he 
arrived on the thirteenth day after the beginning of the pain. Symp- 
toms of general peritonitis were evident, and he died the next day, 
General peritonitis was present, the result of an encysted inflammation 
about the appendix. This organ formed a gangrenous slough lying in 
the cavity of the abscess. 

1 New York Medical Journal, 1866, ii. 40. 



332 FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 

The latency as well as the frequent obscurity of the symptoms of 
appendicular inflammation are thus apparent. The presence, therefore, 
of the symptoms now to be mentioned, in individuals from whom the 
history of one, and particularly of several such attacks is to be obtained, 
is of marked importance in aiding diagnosis. 

Sudden, severe abdominal pain is the most constant, first, decided 
symptom of perforating inflammation of the appendix. It occurred in 
216 out of 257 cases, 84 per cent. In most instances it is present in 
apparently healthy individuals, in a few it follows an attack of diarrhoea. 

The pain is usually intense, rarely slight, and is occasionally accom- 
panied by a chill, or nausea and vomiting. 

The following table shows its localization in 213 cases of appendicitis, 
and, by way of contrast, in 92 cases of typhlitis and perityphlitis: 





Appendicitis. 


Typhlitis and perityphlitis. 




Cases. 


Per cent. 


Cases. 


Per cent. 


[n right iliac fossa 


. 103 


= 


48 


55 


= 60 


" abdomen 


. 76 


= 


36 


31 


= 34 


" hypogastrium 


. 11 


== 


5 







" umbilical region . 


9 


= 


4 


2 


— 2 


" epigastrium . 


4 


= 


2 


4 


= 4 


" stomach 


3 


= 


1 







" hepatic region 


3 


= 


1 







" left iliac fossa 


3 


= 


1 







" right hip and groin 


1 


= 


i 

2" 








Total . . . 213 92 

It is quite probable that the number of cases of more exactly localized 
pain would have been considerably greater had attention been specially 
directed to this point. Many of the recorded cases of abdominal and 
hypogastric pain would undoubtedly have permitted a more definite 
localization, especially as firm pressure often discloses a sensitive spot at 
some distance from the referred seat. Though usually limited to the 
fossa, the pain sometimes extends upward as far as the liver, or down- 
ward to the rectum, testicle, perineum, or thigh. The attack is occa- 
sionally associated with great nervous anxiety, and is at times followed 
by marked prostration, from which the patient rallies in the course of a 
few hours. 

This sudden intense pain is presumably due, not to the actual begin- 
ning of the disease, but to the separation of the fresh adhesions of an 
acute appendicular peritonitis, and often, perhaps usually, to the perfora- 
tion of the inflamed appendix. It generally represents the beginning of 
a more extensive peritonitis. An attempt has been made to ascertain 
the date of occurrence of this most important symptom. This was 



FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 333 



possible in 61 cases of appendicitis, and in 64 cases of typhlitis and peri- 
typhlitis. It occurred as follows : 





Appendicitis. 


Typhlitis and perityphlitis 




Cases 


Per cent. 


Cases 


Per cent. 


On the 1st day in 


. 41 


= 


67 


48 


= 


75 


2d 


. 5 


= 


8 


10 


= 


16 


" 3d 


. 12 


== 


20 


2 


= 


3 


" 4th " 


2 


= 


3 


4 


= 


6 


" 5th " 


. 1 


= 


2 









Total 


. 61 






64 







If the pain is not accompanied by nausea and vomiting, these symp- 
toms are not unlikely to follow. Their occurrence is recorded in 15 
cases of appendicitis, and in 44 out of 209 cases of typhlitis and peri- 
typhlitis. The vomit quickly becomes green in color, but in general 
this symptom is not distressing at this stage of the disease. Diarrhoea is 
rarely present, while constipation is the rule. 

The abdominal pain is followed by fever as the next constant symp- 
tom. The date of its appearance is noted in but 38 cases of appendi- 
citis, and in only 16 of typhlitis and perityphlitis. It was present 



On the 1st day in . 
2d " . 
3d " . 
4th " . 



Total 





Typhlitis 


ppendicitis. 


and perityphlitis 


5 cases. 


6 cases. 


18 " 


7 " 


9 " 


" 


6 " 


3 " 



38 



16 



The temperature is rarely very high, and the constitutional disturb- 
ances usually associated with an elevated temperature are frequently 
slight, if not absent. The maximum recorded in the cases here col- 
lected is 103.5° F., but the range is usually between 100° F. and 102° F. 
With 1 noticed an elevation of nearly 106° F. If violent or extreme 
changes take place, a complication may be expected, as an abscess of 
the liver, or a pleurisy from an extension of the local inflammatory 
process. 

During the first three days following the onset of the pain, micturition 
is occasionally disturbed. Perhaps unusually frequent on the first day, 
it is likely to be difficult on or after the third day. In certain instances 
the use of the catheter is required. A satisfactory explanation of this 
latter feature is to be found in the abundant use of opium, usually neces- 
sary at this stage of the disease. The right testicle may be retracted 
and swollen, in which case the course of the pain is apt to be toward 
this gland. 

The circumscribed swelling in the right iliac fossa now demands con- 



1 Loc. cit. 



334 FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 

sideration. This symptom, when present, is evidently of the utmost 
value in diagnosis, as its appropriate treatment most favorably modifies 
the prognosis. The swelling represents the accumulation of the increas- 
ing exudation, at the outset the product of the peritonitis, and lies 
beneath the adherent coils of intestine which later become attached to 
the abdominal walls. Its usual seat is in the right iliac fossa, below a 
line extending from the anterior superior spine of the ilium to the navel, 
nearer the former and two finger-breadths above Poupart's ligament. 
It may lie nearer the median line or may approximate the iliac crest. 
The swelling may be found in the pelvis in those cases where the ap- 
pendix becomes attached to the peritoneum of the pelvic wall. It is 
rare for the primary swelling to be paracsecal, although this variety 
occurs where the appendix lies embedded behind the csecum. 

The early products of the peritonitis are largely cellular and fibrinous; 
scanty, opaque, greenish masses are found encapsulated. This condition 
is obviously not to be recognized by physical signs. As the liquid exu- 
dation increases, dulness becomes apparent. This sign may be obscured 
by intervening and adherent coils of intestine, especially if they are dis- 
tended with gas, when a superficial gurgling may be recognized. Again 
the contents of the abscess may be partly gaseous, a condition more 
likely to occur later in the course of the disease. A circumscribed re~ 
sistance is felt on palpation. As the part is often extremely sensitive to 
pressure and the abdominal muscles tense, the administration of ether 
or chloroform may be necessary to confirm the diagnosis. A rectal ex- 
amination not infrequently permits the recognition of the tumor which 
abdominal palpation fails to disclose, and should always be made in 
the latter event. Owing to the position of the abscess beneath the trans- 
versalis fascia, and to the fact that it is often covered by adherent coils 
of intestine, a sense of fluctuation is rarely perceived till much later in 
the history of the case. 

The clinical characteristics of the tumor and its composition are thus 
made evident by modified resonance on percussion, circumscribed resist- 
ance on palpation, and a sense of fluctuation. Notwithstanding the im- 
portance of these signs, the records of 257 cases of appendicitis give 
comjmratively little information with reference to the date of their 
appearance. The 209 cases of typhlitis and perityphlitis give a more 
satisfactory result. 



FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 



335 



Dulness was first noticed on the 

1st day in . 

2d " 
3d 

4th u 

5th " 

6th " 

7th " 

8th " 

9th " 

10th " 

Total 



\ppendicitis. 


Tj-phlitis 
and perityphlitis 


cases. 


2 


cases. 


2 " 





" 


1 " 


7 


a 


4 " 


5 


(i 


1 " 


2 


it 


2 " 





" 


1 " 


1 


" 


1 " 


4 


" 


" 


1 


u 


" 


3 


" 



12 



25 



Palpation showed the presence of the tumor on the 



1st day 

2d ' 
3d 

4th ' 

5th ' 

6th ' 

7th ' 

8th < 

9th ' 

10th ' 



Total 





Typhlitis 


\ppendicitis. 


and perityphlitis 


. 1 case. 


4 cases. 


. 3 " 


6 " 


. 4 " 


8 " 


2 " 


8 " 


. 4 " 


3 " 


. 5 " 


6 " 


. 4 " 


4 " 


. 1 " 


7 " 


. " 


11 " 


. " 


11 " 



24 



68 



An attempt has been made to determine the date at which fluctuation 
becomes evident. As a rule, its appearance is so late in the course of 
the disease (after the second week) as to be of little diagnostic value. 
An exploratory puncture with the needle of the aspirator is frequently 
recommended to determine the nature of the tumor. Too much stress 
is not to be laid upon this method of examination. If the aspirator 
fails to show the presence of pus, even after repeated punctures in divers 
spots, it by no means follows that pus is absent. Operators have fre- 
quently exposed the trans versalis fascia over the tumor and have then 
punctured it in several places. Pus not appearing, the wound has been 
dressed. In the course of a few hours an abundant discharge of fetid 
matter has made its appearance in the dressings and at the bottom of 
the wound. 

It is evident from the consideration of the above table, that the pres- 
ence of the abscess may be expected as early as the third day. It may 
be large enough to contain some three pints of fluid on the fifth day. 
The following case reported by Peckham 1 apparently justifies the above 
conclusions. 



1 Boston Med. and Surg. Journ., 1882, cvi. 159. 



336 FITZ, INFLAMMATION OF VERMIFOKM APPENDIX. 

His patient was a man of twenty-seven years of age, who had suffered 
from abdominal pain and diarrhoea for twenty-four hours. He was 
then seized with a severe pain in the right iliac fossa, which was fuller 
than the left, tender, and dull. On the following day the whole abdo- 
men was tender, but there was no complaint of pain. The day after, 
there were great tenderness, dyspnoea, cold hands and feet. The next 
day, the fifth of the disease and the fourth from the occurrence of the 
right iliac pain, the patient died. There was acute peritonitis. In the 
lower part of the abdomen was a space bounded by the bladder, iliac 
bones, and small intestine, the latter pushed up and covered by false 
membrane. In the cavity were nearly three pints of fetid, purulent 
fluid. 

The chief danger from the appendicular peritonitis is that it becomes 
general. Many of the records mention the time of occurrence, not only 
of the iliac pain, but also of the subsequent general abdominal pain. 
The latter is to be regarded as suggestive evidence of the beginning of a 
general peritonitis, as the former calls immediate attention to the exact 
nature of the disease. The date of its occurrence is recorded in about 
one-fourth of the cases of appendicitis, most of which were fatal, while it 
is noted in but about one-tenth of the cases of typhlitis and perityphlitis, 
which were nearly all instances of recovery. 

General abdominal pain was present on the : 



1st 


day 


2d 


" 


3d 


a 


4th 


a 


5th 


a 


6th 


it 


7th 


u 


8th 


u 


9th 


u 


11th 


11 







Typhlitis 


Appe 


sndicitis. 


and perityphlitis. 


2 cases. 


cases. 


11 


" 


6 


tt 


21 


a 


8 


a 


12 


a 


4 


a 


8 


u 





a 


5 


" 


1 


a 


5 


a 





a 


4 


" 





a 


2 


" 





" 


3 


n 





u 



Total . . . . 73 " 19 " 

In one of the cases in which this symptom appeared on the first day 
death occurred on the fourth day. It was stated that there was no per- 
foration of the appendix, although this structure presented a deep purple 
color and contained a fecal concretion. General peritonitis was present 
and a considerable quantity of pus was found in the pelvis and vicinity 
of the appendix. In the other case the general abdominal pain came 
on three hours after moderate pain in the bowels. It radiated from 
the right iliac region. In sixty-six hours the patient was dead. The 
intestines were glued together by a butter-like lymph, but there was no 
serous or sero-purulent exudation. 



FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 337 



It was thought desirable to ascertain the date at which tympanitic 
distention of the abdomen appeared. At the same time it is recognized 
that this sign of a general peritonitis is of considerably less value than 
that already stated. 

Tympanites was present on the 



1st day . 


Appendicitis. 

cases. 


Typhlitis and perityphlitis. 

1 case. 


2d " . 


. 7 


it 


5 cases. 


3d " 


. 13 


a 


8 " 


4th " 


. 14 


it 


2 " 


5th " 


. 3 


a 


2 " 


6th " 


. 1 


a 


1 " 



38 " 19 " 

The second, third, and fourth days are those which include the largest 
number of cases of beginning general peritonitis. In sixty per cent, of 
the cases of appendicitis, as inferred from the nature of the pain, and in 
nearly ninety per cent, as suggested by tympanites. The source of this 
early peritonitis is to be found in most instances in the escape into the 
peritoneal cavity of the inflammatory product encysted near the 
appendix. Although usually small in quantity at this early period, its 
quality is exceedingly acrid. 

The speedy death of the patient almost invariably results from the 
occurrence of the general peritonitis. In 176 cases the day of death was 



as follows : 














On the 2d day in 8 


cases 


= 


4 per cent. 




3d 

4th " 
5th " 
6th " 


20 
12 
20 
16 


it 

a 
a 
u 


= 


11 

7 

11 
9 


it 
a 


98 in the 
1st week, 
56 per cent. 


7th " 


22 


a 


= 


12 


it 




8th " 


21 


" 


= 


12 


l( "N 




9th " 
" 10th " 
" 11th 
" 12th " 


10 

8 
6 
4 


it 


= 


6 
4 

3 

2 


It 


54 in the 
2d week, 
31 per cent. 


" 13th " 


4 


" 


== 


2 


a 




" 14th " 


1 


" 






. . . J 




" 15th " 
" 17th " 
" 18th " 
" 19th " 


3 
1 
1 
1 


a 
it 

a 








8 in the 
3d week, 
4 per cent. 


" 20th " 


2 


it 






■ ■ • . 




In the 4th week 


7 


a 


= 


4 


it 




5th " 


4 


a 


== 


2 


u 




7th " 


4 


a 


= 


2 


a 




8th " 


1 


it 


= 


I 


a 




no. clxxxiv. — October, 1886. 






22 









338 FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 

In fatal cases sixty-eight per cent., more than two-thirds, die during 
the first eight days, and two-thirds of these die between the fourth and 
eighth days inclusive. 

Errors in the diagnosis of appendicitis have been numerous, chiefly 
because the cardinal symptoms of localized pain, general heat, and 
circumscribed swelling have not been duly appreciated in their defined 
sequence. Again, the extreme rarity of acute perforating inflammation 
of the caecum, as compared with that of the appendix, has not been made 
sufficiently conspicuous. The acute form of perforating appendicitis has 
been confounded with inflammation of the caecum or typhlitis in an exact 
sense, intestinal obstruction from intussusception or strangulation, pelvic 
peritonitis (hematocele) of vesical, ovarian, tubal, or uterine origin, 
psoitis, and renal or biliary colic. More rarely a movable kidney or a 
foreign body in the badder has been suspected. 

The chronic appendicular peritonitis and the chronic paratyphlitis 
resulting from a perforated appendix, have been confounded with the 
results of caries of the spine and hip-joint, suppurative nephritis, intes- 
tinal tuberculosis, and cancer of the caecum. An appreciation of the 
previous history of the patient, the seat and character of the pain, the 
period of occurrence of the fever and the date of the appearance of 
the tumor are necessary for an eliminative diagnosis. 

A primary perforating inflammation of the caecum is extremely rare 
even in chronic dysentery or in chronic tuberculosis. In an extensive 
research into the literature of the subject but three cases of acute 
primary perforation of the caecum have been found. One from a fish- 
bone, another from a pin, and the third from strangulation of the 
bowel. Two cases of rupture of the caecum are recorded. So rare is 
the affection in question that the possibility of a primitive, perforating 
caecitis may be disregarded. Bartholow's 1 communication on this subject 
relates rather to the secondary perforation of the caecum from without. 

Stercoral caecitis, on the contrary, is exceedingly common, and is, 
perhaps, the most important of all the conditions with which the perfo- 
rating appendicitis may be confounded. The history of this affection 
usually makes evident a period of protracted constipation in a person 
not especially young, vigorous, and apparently healthy, who may have 
had similar attacks. The pain is trifling for a long time, and the sensi- 
tiveness slight. Fever is absent, or of late occurrence. The tumor is 
present at the beginning as a distinct nodular or doughy mass, elongated, 
and in the lumbar region. It is unnecessary to say that from a stercoral 
caecitis may arise a perforative appendicitis which may end in perfora- 
tion. Many of the so-called cases of typhlitis terminating in resolution, 
associated with fecal retention, and persisting after the removal of the 
feces, are undoubtedly of this nature. 

1 American Jouknal of the Medical Sciences, 18G6, N. S., Hi. 351. 



FITZ, INFLAMMATION OF VEEMIFOEM APPENDIX. 339 

Intestinal obstruction from intussusception or strangulation is charac- 
terized by the frequent absence of a suggestive previous history. The 
pain is not so localized or intense, and the fever is not conspicuous at an 
early stage. The abdomen is distended and tympanitic at the outset, 
and is, at the same time, unusually sensitive. Borborygmus and per- 
ceptible movements of the intestine are associated with or followed by 
fecal vomiting. Obstinate constipation and the retention of flatus are 
noticeable. The tumor is absent when the intestine is strangulated, and 
it is elongated, sausage-like, usually following the course of the colon 
when intussusception is present. Tenesmus and the rectal discharge of 
bloody mucus are important signs of the latter affection, though they 
may occur when the appendix is inflamed. 

As four-fifths of the cases of appendicitis occur in males, and as 
pelvic peritonitis suggests a doubt as to its diagnosis almost invariably 
in females, it is evident that the question of sex is of eliminative value 
in certain cases. But the doubt may arise in the case of the female. 
Barker 1 has reported two cases, the one of hematocele, fatal in forty- 
eight hours, diagnosticated as inflammation of the appendix. The second 
patient also died on the second day ; the autopsy showed an inflamed 
appendix and pregnancy, although the patient wns supposed to have 
had a hematocele. Suppressed catamenia and the incipient symptoms 
of appendicitis not infrequently coexist. Again, the occurrence of 
symptoms of appendicitis within twenty-four hours after delivery is 
occasional, and more rarely it represents a cause of abortion. In general, 
the symptoms and progress of a pelvic peritonitis of pelvic origin would 
not be likely to suggest an inflamed appendix. The symptom wdiich is 
of the greatest value in determining the onset of an appendicitis after 
delivery, is to be found in the rapid development of the tumor without 
an obvious cause. When the appendicular peritonitis is pelvic in its 
localization, the previous history and the absence of evidence of disease 
of the genital tract are to be relied upon to direct attention to the 
appendix as the cause. 

An inflammation of the psoas muscle may be the result of an appen- 
dicitis. If due to other causes, and acute in character, the digestive 
disturbance is lacking, and the pain and sensitiveness are less, the tumor 
is more vaguely defined and tympanitic from its deep seat, while the 
motion of the leg is early impaired. A primary, acute, suppurative 
process is of doubtful occurrence. 

A biliary colic is rarely likely to suggest an inflamed appendix. The 
seat and nature of the pain, the absence of fever and peritonitis during 
the first week, and the possible occurrence of jaundice, would tend to 
eliminate this affection. 

1 New York Medical Record, 1880, xviii. 663. 



340 FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 

In the passage of a renal calculus the seat and character of the pain 
differ. Fever and the iliac pain are absent. There is no iliac tumor, 
and the examination of the urine may indicate the probable presence of 
a foreign body in the ureter. 

In chronic cases of inflamed appendix the abscess is evident, and its 
treatment apparent. It may be mistaken for a psoas abscess of spinal 
origin. If the latter affection is present, evidence of disease of the ver- 
tebra is usually to be obtained. In disease of the hip-joint the impaired 
mobility and localized sensitiveness of this articulation will be found 
more extreme than is apparent in the flexed and adducted thigh, usually 
connected with a chronic perityphlitic abscess. 

The history of the cases of intestinal tuberculosis, chronic suppurative 
nephritis, and cancer of the csecum are sufficient to eliminate these causes 
of iliac and lumbar tumors, when disease of the appendix is under con- 
sideration. 

Perforating inflammation of the appendix sometimes proves fatal from 
shock. Death usually follows from the production of a general perito- 
nitis by the direct extension of an appendicular peritonitis, or by the 
rupture of adhesions producing an intervening, encysted, peritoneal 
abscess. A general peritonitis may also occur by the intervention of a 
mesenteric thrombophlebitis and its continuance to the portal vein and 
liver, with or without portal embolism. Among the 257 cases of per- 
forating appendicitis are 11 of pylephlebitis. 

In the protracted cases death may result from exhaustion. Shock 
proves fatal within the first two days, death from an extended peritonitis 
within the first week, and from a secondary general peritonitis, as a rule, 
during the first two weeks. 

The termination in resolution of a perforating appendicitis undoubt- 
edly occurs, but our present sources of information give no absolute 
evidence as to the relative proportion of this class of cases to those 
ending fatally. The consideration of a large number of cases of typh- 
litis and perityphlitis, offers a suggestion as to the possible frequency. 
Of 180 cases thus designated there terminated 

By resolution 58 = 32 per cent. 

Spontaneous evacuation . . . . 33 = 18 " 
Operation 89 = 50 " 

180 

It will be generally admitted that the spontaneous evacuation of a peri- 
typhlitic abscess is an event to be anticipated and guarded against. Apart 
from the consequent dangers which may result, possible fatal complica- 
tions which may precede the time of its expected occurrence are a suffi- 
cient warning. It is, therefore, important to bear in mind that two- 



FITZ, INFLAMMATION OF VERMIFORM APPENDIX. 341 

thirds of the cases of typhlitis and perityphlitis above tabulated, were of 
unquestioned abscess. 

The termination by resolution of nearly one-third may seem a suffi- 
cient warranty for recognizing this result as frequent enough to be 
anticipated in all cases. 

That this conclusion is not justified appears from the fact that twelve 
of these, about one-fifth of the entire number, thus terminated at the 
end of the second week. Operative interference is demanded before this 
time in two-thirds of all cases, hence but one-fourth may be expected to 
undergo resolution. 

An additional argument against the plan of waiting with the hope of 
the occurrence of resolution, is to be found in the frequency of recurrent 
attacks. Recurrence is recorded to have taken place in 28 out of 257 
cases of appendicitis, and in 23 out of 209 cases of typhlitis and peri- 
typhlitis ; that is, in about eleven per cent, of each. It is at least sugges- 
tive of the importance of not waiting too long for resolution, that the 
number thus terminating during the last two days of the seco